Sheridan Teal House

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• 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

We assessed 5 quality statements from this key question. We have combined the scores for this area with scores based on the rating from the last inspection undertaken in 2022, which was good. Our rating for this key question remains good. We carried out this focused assessment in response to concerns raised, some of which related to the culture of the service including management of freedom to speak up concerns and issues around the equality and diversity of the service. We found that processes were in place to support staff wishing to raise a concern. The provider had carried out focused work around equality and diversity. This included development of an Equality, Diversity and Inclusion strategy, all staff being required to undertake equality and diversity training as part of mandatory training requirements and introduction of an equality, diversity and inclusion staff survey.

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.

We spoke with leaders of the service who told us how they had recently reviewed and updated the vision and values. This focused on working with staff to obtain feedback and include them in shaping the new vision and values. Leaders told us they considered the vision and values in everything they do and gave an example of a new workstream having been refused to avoid additional pressure on staff. All of the staff we spoke with and received feedback from demonstrated a commitment to providing good quality, safe patient care.

In February 2023 the provider commenced the ‘LCD Way’ project to review and define the desired culture of the organisation. This included a number of staff surveys to look at thoughts on the current vision and values and what values staff would relate to most as individuals. The surveys were followed up with engagement events and focus groups to further define the values. As a result of this work, and with input from all staff groups, the following values were adopted; Kindness and Respect, Fairness and Consistency and Honesty and Integrity.

Feedback we received from staff was mixed regarding managerial support at an operational level. Some staff members felt fully supported by managers during their shifts. However, others told us there were inconsistencies and that in some cases managers were less supportivewe heard from others that they felt there were inconsistencies and that in some cases managers were less supportive. Concerns were also raised regarding competencies in relation to management of case queues in order to avoid an increase of Operational Pressures Escalation Levels (OPEL). We discussed this with the provider as part of our assessment and received assurance that this would be reviewed. We spoke with a member of the leadership team who was committed to ensuring the culture of the organisation was embedded across all 14 sites. We received positive feedback from staff regarding leaders at director level who were reported to listen and have a desire to make positive changes to the organisation.

The provider had developed the values, which had been created with input from all staff groups, into behaviours. This was shared with all line managers and clearly outlined acceptable and unacceptable behaviour. As part of the ‘LCD Way’ project, the provider had introduced a new employee recognition programme to acknowledge individuals who demonstrate behaviours which were in line with the LCD way. Nominations could be made by all staff and successful nominees received an award and donation to their chosen charity. As part of the assessment process, the provider shared a business plan presentation with us. This clearly outlined strategic goals, priorities, business plan, risks and assurances. Culture and values was identified as a dedicated workstream and we saw that a values and culture review was in progress.

All of the staff we received feedback from were aware of the Freedom to Speak Up policy and the named Freedom to Speak Up Guardian. The majority of staff felt they would be supported to raise concerns and that these would be acted upon.

The provider had a Freedom to Speak Up policy and a named Freedom to Speak Up Guardian. We noted that there was no external Freedom to Speak Up Guardian identified, however the policy directed staff to NHS England and Care Quality Commission in the event they did not want to raise their concerns internally. We reviewed findings of an investigation carried out by the provider in response to concerns being raised. The provider held a Freedom to Speak Up register and we saw that 5 concerns had been raised since April 2023. Information contained within the register was limited regarding nature of concern however, we saw that 1 had been categorised culture, equality and inclusive behaviours and 1 related to equity, diversity and inclusion. We were informed by the provider following our assessment, that full details of concerns were recorded as part of the incident reporting system.

Staff feedback regarding the service was mixed. We spoke with, or received feedback, from 16 staff members as part of this assessment. The majority of staff were positive about the working environment and felt supported by their line manager and duty managers. A number of staff told us they had seen improvements to the culture of the service following a new addition to the leadership team. However, some staff felt that they were treated differently on occasion by the operational management team due to their cultural backgrounds. We raised these concerns with the leadership team as part of our assessment process.

We saw that equality and diversity training was included as part of the providers statutory and mandatory training requirements. When reviewing records, we saw that 99% of staff had completed this training. The provider had implemented a new equality, diversity and inclusion survey. This was developed to understand employees perception of working for Local Care Direct and whether they felt they were being included and belonged to the organisation.

Leaders demonstrated a good understanding of the challenges faced by the service and had taken steps to address these. For example, the provider had undertaken capacity and demand analysis in order to ensure clinical rotas were planned to best meet need. Individual rotas had been designed using intelligence from previous years. This included summer and winter profiles and standard Bank Holiday rotas. Staff we spoke with were able to give examples of inappropriate referrals into the service. These included cases which would have been better suited to signposting directly to hospital and those that would be better managed by the registered GP practice. We were informed by leaders that these issues had been raised with commissioners and other stakeholders, however due to pressures on the wider healthcare system, no solution had been reached. We heard of how the provider supported the wider healthcare system to promote improved patient experience. An example of this was the Gold Line Service for patients in the Bradford area. This service provided support to palliative care patients within their own homes, reducing the need for admission to hospital or attendance at emergency departments. We reviewed an audit of cases into the service for May 2024 and saw that of 356 cases, 332 were managed by the provider with no need for onward referral or hospital admission. At the time of our assessment the provider was working with commissioners to look at improving the efficiency of this service and were exploring options such as virtual prescribing.

The provider had a comprehensive clinical risk assessment in place which was regularly reviewed. This showed evidence of discussions with other stakeholders, for example NHS West Yorkshire Integrated Care Board, Yorkshire Ambulance Service, West Yorkshire Urgent Care Commissioners and West Yorkshire Palliative and End of Life Care. We saw that steps had been taken to mitigate risk in all cases. However, some risks were moderate and above with little reduction as a result of action taken. For example, 3 of the 11 risks we reviewed were assessed as being major and very likely to occur, 1 was critical and very likely to occur. We saw that despite the action taken by the provider, the risk rating remained the same. We were informed by the provider that this was due to the limited support available from the wider healthcare system. We reviewed the operational risk register and found this to be detailed, however this indicated that in some cases the provider appeared to have been left to absorb the risk of other services with no clear routes to seek support from external partners. We saw evidence that the provider proactively escalated these risk with the commissioners and other stakeholders. The provider met regularly with other stakeholders to monitor performance, risk, service redevelopment and improvement. There were processes in place to ensure information was communicated to staff. This included a weekly bulletin providing information regarding changes to the service and key messages e.g. changes to protocols and patient safety alerts. The provider also used the alert function on the clinical system to share important information to all staff. The provider carried out regular audit activity to monitor management of cases including, case closures and patients who did not wish to proceed with access to treatment.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.