Cudmore House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service had a clear vision and strategy to deliver high quality care and promoted good outcomes for people. Staff were clear on their individual responsibilities and knew who was accountable for each aspect of the service. Leaders had oversight to ensure the effective running of the service and were capable, compassionate, and inclusive. The service encouraged the duty of candour, openness, and honesty.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders at the service had a detailed vision and values for the service. Some staff told us they felt engaged by leaders at the service. They told us they were listened to and had contributed to the development of the service. However, some staff told us they did not feel included, or their ideas and concerns listened to following changes implemented during the development of the service. They told us they felt changes had been imposed upon them without any consultation. Staff were encouraged to keep their knowledge and skills up to date in line with continued professional development to support the service. Leaders informed us there was a strong emphasis on the safety and well-being of staff.

The service had a quality improvement plan to progress their vision and commitment to people. The plan included areas the service wanted to focus on such as improving clinical governance arrangements, quality assurance, key roles and responsibilities and urgent and primary care services.

Views from staff regarding the accessibility of leaders was mainly positive. Staff felt supported by their line managers who were visible and approachable throughout the operational period, with an out of hours on-call system for senior management support during these times. However, staff told us senior managers were not visible during weekends and overnight and did not visit the treatment centres. Leaders supported staff in professional and personal matters. Leaders were aware of the challenges of delivering good quality care and were striving for improvements. Leaders demonstrated the skills and knowledge required to influence others and understood their role in leadership.

Leaders included staff in their planning for the future. The service had identified the actions needed to address challenges and make improvements.

Staff knew what a freedom to speak up guardian was (FTSUG) but not all staff knew the name of the service’s FTSUG.

The service had staff who took on the role of the FTSUG. They were a point of contact for any member of staff to raise concerns about colleagues, the service or leadership. There were policies and processes to support speaking up and these were accessible to all staff. However, both the FTSUG’s were part of the senior leadership team and staff told us they perceived this as a barrier to speak up when they had concerns. Leaders were aware of this and were identifying alternative members of staff to take on the role, to address and remove this barrier.

The service actively promoted equality and diversity. Staff had access to an equality, diversity, and inclusion policy and had completed relevant training. Newly recruited staff completed a monitoring form, so the service was aware of the diversity of their workforce.

Staff and leaders were clear on their individual roles and responsibilities including safeguarding and infection prevention and control (IPC). Patient confidentiality and information security was understood and upheld. Staff told us learning and development opportunities were identified during annual appraisals and appropriate training was sourced. Staff were encouraged to attend meetings where updates, and new information was shared. Actions from these meetings were recorded and accessible to all staff.

There were clear structures, processes and systems to support good governance. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. There were clear and effective processes for managing risks, issues, and performance. However, while staff were encouraged to maintain checks on their own clinical equipment the provider was not able to evidence this process had been completed, for all staff and equipment.

We received no specific feedback in this area.

Staff worked with stakeholders to build a shared view of challenges and of the needs of the population. Leaders told us they engaged with services they referred to regularly for feedback on the quality of referrals. Staff and external partners' views and concerns were encouraged, heard and acted on to shape services and culture.

Partners did not provide feedback about partnerships and communities.

The service understood its patient population and had adapted its service to deliver to the community. The service had engagement mechanisms with both commissioners and partner organisations in the area.

The service understood its patient population and had adapted its service to deliver to the community. The service had engagement mechanisms with both commissioners and partner organisations in the area.