The Jersey Practice

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

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 in April 2016, we rated this key question as good. At this assessment, the rating has changed from good to requires improvement. The service was in breach of regulation 17, related to good governance.

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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff understood the direction and culture of the service to be patient-focussed and high-quality care.

Staff told us leaders in the practice were approachable and responded to any concerns raised. The leaders informed us that they work with the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voices would be heard. Staff were aware of how to raise concerns internally and externally. The service had a whistleblowing policy with the information of how staff can speak up externally and staff we spoke to demonstrated awareness of this.

The service valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff had awareness and training on equality.

The service did not have clear responsibilities, roles, systems of accountability and good governance. This was related to administrative oversight, effectiveness of the processes or systems, as revealed by the evidence obtained during the assessment process. During the site visit, we found that there was no effective system to track staff training and ensure safe recruitment processes were followed. For example, we reviewed 5 staff files and there were no references obtained for 4 of the staff records. In addition, there was no evidence of assurance completed by the service that the staff could work with patients who may be at risk of abuse and harm. Following the site visit, the service informed us that the information will be obtained and staff files updated while the Disclosure and Barring Service (DBS) risk assessments will be included in yearly appraisal process going forward.

During our visit, the leaders were unable to show us they had a system to assure themselves of the competency and validity of all clinical staff working at the service. In addition, the leaders did not demonstrate oversight of building maintenance completed by the building owner including cleaning schedules and audits and did not follow up with the building owner to ensure all maintenance checks were completed promptly and correctly. However, the service provided evidence of correspondence with the building owner following the site visit feedback, but the concerns were not yet addressed. For example, records reviewed on site showed that taps rarely used, which were meant to be flushed twice weekly according to the water safety risk assessment, were last flushed over five weeks earlier.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. The service was actively involved in primary care initiatives within the primary care network. However, we found that the Patient Participation Group (PPG) was not operating effectively to support improvements in service delivery. The PPG members we spoke with indicated that PPG meetings were not organised and recorded consistently.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. Learning from incidents and complaints was not always shared with staff and discussed at team meetings. The meeting minutes seen by CQC lacked evidence that learning was consistently embedded in daily practice and recorded for future reference. There was no evidence that Patient Participation Group (PPG) meeting minutes were shared with the patients and there was no structure to the PPG to ensure improvement of the service delivery.