Netherley Health Centre

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 assessed all quality statements under this key question. This is the first rated assessment of this service since the provider took over the contract. We rated this key question as good.

This service scored 71 (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 shared vision, strategy and culture that staff in all areas knew, understood and supported.

The culture of the service was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively.

Leaders were visible and they understood the context in which they delivered care, treatment and support.

The leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

Members of the staff team in a range of roles told us that communication across the service was effective.

The provider monitored and acted upon data about outcomes for patients. They made improvements when required.

The provider fostered a positive culture where people could speak up without fear of detriment and their voice would be heard.

Leaders encouraged staff to raise concerns and promoted the value of doing so.

Staff were provided with information about speaking up and they told us they felt confident to raise issues. However, not all staff felt these would be acted upon and some felt they would like more support from managers and leaders.

The practice had established freedom to speak up arrangements. A designated member of staff was the ‘freedom to speak up’ person that staff could approach. There was also a whistleblowing policy.

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

Reasonable adjustments were made to support staff to carry out their roles. Staff with caring responsibilities were actively supported with a flexible approach and changes to schedules to accommodate their needs.

Staff understood their roles and responsibilities and those of other members of the team and lines of accountability were clear.

Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. The provider had an equality, diversity, and inclusion policy.

There were clear and effective arrangements for governance, management and accountability.Much of the governance was carried out at provider level with only some carried out at a practice level. We noted that some staff felt that the governance/ leadership of the service could feel ‘top heavy’ and they would like to see more emphasis for staffing and management at a local level.

All staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks.

The provider had established governance processes that were appropriate for the service. Clinical governance was effective to provide good quality care and treatment. The provider used data to monitor and improve performance. A regular suite of searches of the clinical record system were being run to identify patient needs and ensure these were being met.

The practice used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data and records. Staff took patient confidentiality and information security seriously.

There were arrangements for identifying, managing, and mitigating risks. A major incident plan was in place.

The provider worked collaboratively and in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop services.

The practice did not have an active Patient Participation Group (PPG). A designated member of staff took the lead for patient engagement, and they told us of the events and actions they had taken and were planning to encourage patient participation, including attempts to encourage uptake of a PPG.

There was a focus on continuous learning and improvement across the service. The provider supported learning and innovation and promoted an open, learning culture. Leaders demonstrated that they understood the challenges to quality and sustainability.

The provider was proactive in support the patient population and reducing secondary care admissions. For example, through the introduction of a designated lead nurse role to carry out reviews and support patients living with heart failure.

There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence.

The provider had established a research hub based within the practice and was embedding a research culture across the organisation. They were engaged in research activity, and they were looking at ways to expand and secure future research opportunities.