Island Health

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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 all 7 of the quality statements from this key question – 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 and learning, improvement and innovation. We rated the Well Led key question as requires improvement. During this assessment, we identified areas where oversight of risk needed strengthening. This included, safety netting cervical screening test results, management of risks in the service environment, staff recruitment checks and maintaining staff immunisation history.

There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care. Leaders implemented quality frameworks to improve equity in experience and outcomes for people using services and tackle known inequalities. We found the service had a shared vision and strategy for the future which considered the needs of people and communities that used the service. Leaders understood local population issues, and the challenges and priorities for their service. Leaders proactively supported staff and collaborated with partners to deliver care that is, integrated, person-centred and sustainable, and reduced inequalities.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The leaders explained they had taken over the service in April 2023 and they had worked with the staff to find a shared direction and culture. This was based on transparency, equity, equality, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders promoted people’s equal rights and ensured there was no workforce inequalities.

Leaders told us that they had successfully increased their permanent workforce to manage high demand. Leaders used appointment activity data for workforce planning and to manage capacity and demand to increase access for patients.

Staff reported that leaders were visible and approachable. There were named leads in place for key areas and staff were clear about their roles and responsibilities. Staff had access to the policies and procedures, which were reviewed on a regular basis. Staff told us they could provide feedback and they had opportunities to suggest new ideas and this was encouraged by managers and leaders.

Leaders monitored performance and quality within the service, however this was not always effective. For example, the leaders did not always have clear oversight of risks that affected the service and staff had not always followed policies. There was evidence that some control measures have been put in place to manage risks identified, but we found leaders had not regularly reviewed all safety risks to ensure they had appropriate mitigation. For example, we found processes to ensure safety netting of cervical smear tests and maintaining staff immunisation records, required improvement. The leaders held weekly GP partners meetings and management team meetings monthly to review performance. Staff had been allocated roles and had job descriptions in place. Staff were offered regular review, supervision and appraisal. The service had regular meetings with all staff groups where information was communicated and shared within the service. Meeting minutes we looked at had recorded clearly what had been discussed. There was evidence of quality assurance activity and clinical auditing and this was used to make improvements. There was a clear and appropriate approach for supporting and managing staff when their performance was poor or variable. There were arrangements to deal with any behaviour inconsistent with the vision and values. The service used digital services securely and effectively and conformed to relevant digital and information security standards. There were clear arrangements in place for the availability, integrity and confidentiality of data, records and data management systems.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support. However, leaders had not always demonstrated the capability to ensure safety risks were well managed. Leaders were visible within the service and led by example to their staff team, demonstrating inclusive behaviours. The service had carried out an independent staff wellbeing survey in September 2024, 11 out of 29 staff responded, 89% felt the partners valued and recognised the contribution of the employees. The leaders explained all of the partners worked at the service during the week and the service had a lead GP who worked full time. The leaders explained the service offered flexibility in the hours staff worked to enable staff to meet their cultural and caring responsibilities. The staff we spoke with and who completed a feedback questionnaire stated they felt supported by the leadership team.

The service had not always ensured staff were aware of their roles and responsibilities to ensure risks are well managed. For example, staff had not followed statutory guidance in relation to maintaining staff immunisation records. Where staff had exercised their right to refuse immunisation, the practice did not have a documented risk assessment to assess the risks to staff and they had not fully considered the risks to patients. However, there was evidence that for most staff the relevant immunisation information had been collected and recorded. Staff had access to an employee handbook and the service had a locum policy. Service staff attended local forums groups which would be beneficial to the service in order to access support and development in their roles. The partners explained that they had a succession plan in place for the service. Staff had access to training and development and an occupational health and wellbeing programme.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff we spoke with were confident about how they could raise concerns and that they would speak up if they had a concern. However, one member of staff who gave us feedback, did not understand what whistleblowing is. Staff felt that leaders were approachable, listened and acted in response to matters raised. Staff were not fearful of any repercussions if they spoke up.

There were processes to encourage staff to speak up. The practice had a whistleblowing policy with guidance for staff to approach external organisations should they not be confident to raise concerns internally. The whistleblowing policy did not include the contact details of the Freedom to Speak Up guardian. However, staff told us the service had appointed a freedom to speak up guardian. Processes also ensured that when things went wrong, people received an apology and were told about action that would be taken to prevent the situation happening again.

The service valued diversity in their workforce. Leaders worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they work well as a team, and they do what they can to help each other. The leaders explained that they provided flexible working arrangements and time for staff to follow their religious and cultural beliefs. Leaders had provided a multicultural prayer area on the premises, for staff. Staff had access to an employee assistance programme, continual professional development and support and mentorship, rewards and recognition, and celebrations.

The service had processes in place to enable staff to raise their concerns, staff had the opportunity to raise issues at meetings, supervision and appraisal, and the staff survey. Staff had access to equality training to help them understand about protected characteristics, bullying and harassment. Staff had completed equality and diversity training and learning disability awareness.

Leaders told us quality and improvement audits were completed monthly but leaders had failed to identify gaps we found during our assessment. For example, the provider could not demonstrate they had effective oversight over governance processes to identify, monitor and manage all risk and performance issues. Specifically with oversight of risk assessments of the premises, recruitment checks, maintaining records of staff immunisation and safety netting of cervical screening results.Staff could access all required policies, but leaders had not ensured that staff had always followed them. Leaders and managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Any actions arising from these meetings were clearly recorded and shared with staff. Staff took patient confidentiality and information security seriously, there were policies and procedures to ensure this. The practice had completed a data security and protection toolkit self-assessment to demonstrate it was practising good data security and that people’s personal information was handled correctly. Leaders held finance and management team meetings where the management and sustainability were reviewed. Leaders told us they prioritised consultation with building managers in order to accelerate remedial work to improve the service premises. The leadership team had recruited to new positions at the service and had sought staff and patient views about any changes they had made. The service had carried out an independent staff wellbeing survey in September 2024.

The service was not consistently following their policies, for example related to safe staffing and recruitment. Leaders had not always followed statutory guidance in relation to maintaining staff immunisation records. The service did not always detect and control potential risks in the care environment. They did not always make sure facilities, and equipment supported the delivery of safe care. The system to monitor the management of safety risk in the service environment was not effective. We noted there was some inconsistency in recording actions and review dates on the service risk register. Following our inspection, the provider sent us their updated risk register, to ensure remedial actions and recommendations were recorded and actions on identified safety risks were being monitored effectively, to improve the service. Following our inspection, the provider sent us a copy of a letter from the building landlords confirming the landlord’s responsibility to maintain the building and that the service were in regular communication with the landlord and building management team, regarding the building issues.The service held monthly quality and performance meetings which reviewed compliance, and significant events, training and audits. Also, a monthly management team meeting which reviewed risk, patient safety and quality improvement. The service used technology to enable them to continually monitor their performance, for the management of health conditions and access to the service. The leaders explained they used this information to continually assess whether they had sufficient staff skilled staff to provide a safe service. The service had a business continuity policy and a major incident plan was in place.

We could not collect the evidence to score this evidence category.

Leaders told us they collaborated with stakeholders and had integrated care meetings with district nurses, care agencies, mental health services, care coordinators and palliative care services. They had multidisciplinary team meetings monthly to discuss and improve outcomes for people with complex needs and a monthly meeting with the health visitors to discuss child safeguarding. The service was actively involved in their local primary network, where they worked with other services to improve the local health inequalities. The leaders explained how they engaged with patients. For example, they had a quality improvement project where they engaged with the patients when they changed to the online patient consultation form. In addition, they held patient participation meetings, where patients could contribute their views and had a monthly newsletter to inform patients of any changes.

Leaders understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared examples of information and learning with partners and collaborated for improvement. For example, the service had held a stakeholder event in March 2024 which was hosted and chaired by one of the Island Health GPs to hear what the local concerns and key health priorities of the local community were. The stakeholder event was attended by local housing associations, voluntary organisations, public health officials and a local councillor. Key themes emerged, particularly the issues of isolation and loneliness, which adversely affected the management of long-term conditions such as hypertension and diabetes. Staff told us that the findings from the stakeholder event had fed into the larger work planned by the service’s health and wellbeing team.

The service worked closely with local GP practices and across the PCN to identify and improve local health inequalities. They had sought patient feedback to any changes at the service through surveys and engagement sessions. Learning from deaths was discussed in integrated care meetings to allow cross partner learning and deaths were also reviewed at clinical meetings team held weekly.

The service had a focus on continuous learning, innovation and improvement across the organisation and local system. The GP Partner was the clinical director for the Primary Care Network providing leadership for the whole PCN. GPs at the service led on joint working across primary care and health systems in their local area. One of the GPs was the Mental Health lead for PCN transformation. Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted quickly on issues we identified. Leaders told us that there had been steady growth of the service list size with a 5.4% average annual growth rate. Staff told us the service engaged with parents at a local primary school where GP’s led education sessions aimed at parents, educating them about healthy eating, managing minor illnesses, and providing asthma and anaphylaxis training. The scheme of work around healthy eating was well received and was being used in other schools as well. The health coaches from the service’s Wellness Team also run sessions with parents around mindfulness and meditation, which staff told us was well received and is being rolled out to other schools in the area. Staff told us they felt proud to be a training service. The service had 4 qualified GP trainers and 3 GP registrars. One of the GPs was a Programme Director for GP training in Tower Hamlets. Leaders told us they supported trainee service nurses through the Tower Hamlets GP Federation’s Open Doors programme which provided education and support for nurses, and health care assistants working for GP surgeries. One senior GP had led on recruitment to the ARRS roles for the PCN.Leaders had encouraged employees to explore opportunities for development. In March 2024, the provider had supported the service phlebotomist to train to become a health care assistant. The senior GP partner regularly held case discussion meetings for clinicians at the service and across the primary care network.

The service had some strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work, including research, and embedded evidence-based practice in the organisation.The service had management team meetings monthly to review the strategic direction, values, staffing and update on organisational priorities. However, the processes the service used to monitor and review activity did not always give a clear, accurate and current picture of risk that led to safety improvements. The provider did not have effective processes to enable them to understand current and future risks. This included safety risks in the building which was managed by another organisation. Leaders did not have evidence of an agreement or written long term refurbishment plan in place.