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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 looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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.

The provider had a clear vision and strategy to provide high-quality primary care services by experienced clinicians.

The provider aimed to provide convenient, equitable and high-quality healthcare that is patient-centred and accessible to all, easing pressure on NHS services and filling gaps in community care.

At the time of our assessment, attempts to engage with NHS bodies to develop this work had not progressed. Therefore, the provider’s main focus was a mobile vaccination service, occupational health services and private GP consultations as required.

The provider understood the context in which they delivered care, treatment and support and embodied the culture and values throughout the organisation. The provider had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Although there were no staff directly employed by the service at the time of our assessment, the provider had appropriate policies and procedures in place to support staff as the service expanded.

The provider had appointed an external Freedom to Speak Up Guardian and there were governance arrangements in place with an external organisation to support any future staff through the process.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place.

The provider had a good understanding of their responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The provider worked with an external consultancy company to manage governance systems within the service. This ensured the provider had independent oversight and challenge if required.

The provider held monthly governance meetings with the consultancy company and had set agenda items for discussion. This included the risk register, medicines management, infection prevention and control, performance reporting, incidents, complaints and safeguarding.

There was a comprehensive business plan in place which clearly identified the services strengths, weakness, opportunities and threats. The provider had plans in place to address these.

The provider took patient confidentiality and information security seriously. All patient records were stored electronically using a dedicated clinical system.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Leaders encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The provider established the service to support national priorities aimed at reducing unnecessary hospital admissions. The service delivered community-based diagnostics, including ECGs, allowing people to access timely assessment and treatment locally, helping to prevent deterioration and avoid hospital attendance where possible.

Following our last inspection, the provider had developed a bespoke computerised application to improve governance arrangements within the service. This included the ability to track referrals to other services, monitoring of emergency medicines and equipment and staff training.