Is it Well-Led?

Inspection Question Is it Well-Led? The Report from CQC

The CQC inspector’s rated well-led as Good


  • The service leaders were able to articulate the vision and strategy for the service. Staff worked together to ensure that service users would receive the best care that the service could provide. The provider was able to provide all service users with timely access to the service. The service had a complaints procedure in place and it used service users’ feedback to tailor services to meet user needs and improve the service provided.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • There was no indication that the service monitored its progress against delivery of the strategy.


The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. For example, when a service user tripped on the step outside of the service building, they were apologised to by staff and brought back into the service so that a member of clinical staff could make sure that they did not sustain an injury. In addition, the service contacted the service user by telephone the following day to ensure that they were ok after the accident. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. As a new provider, the service had not yet commenced regular annual appraisals in the last year. We were told that these would commence later in the year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams. We noted that the service had staff meetings on a regular basis.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships and joint working arrangements promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities. The service had appointed members of staff as leads for specific roles such as safeguarding, infection and prevention control and managing complaints.
  • Leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. However, we noticed that the service business continuity policy had not been fully completed to include a risk score for the identified hazards to the business.

Managing risks, issues and performance

There were clear and effective clarity around processes for managing risks, issues and performance.

  • There was a process to identify, understand, monitor and address current and future risks including risks to patient safety, however this was not always acted upon. This was evidenced through non-completion of several actions of the most recent health and safety evaluation audit.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • As the service had not conducted any clinical audits, there was no evidence to measure that clinical audits had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality via the audit conducted on post-operative service users experiences.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of service users.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. The service had its own bespoke records system to keep service users records. This system was backed up regularly. The system could only be access with a unique user ID. All staff at the service had been given a user id and dependant on the role performed, was given restricted or all access to records held. The system was able to provide an audit trail of who had accessed records on the system.

Engagement with patients, the public, staff and external partners

The service involved service users, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from service users, staff and external partners and acted on them to shape services and culture.
  • Staff could describe to us the systems in place to give feedback. The service told us that service users could provide feedback on the day of their appointment using the electronic feedback system located at the reception desk. In addition, the service sent service users a feedback form shortly after their attendance at the service, which gave users the chance to give in-depth feedback about their experience at the service. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

View details from CQC Page

The 5 Areas which the CQC investigated.

Download CQC inspection report PDF

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