Hartshill 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 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

This is the first inspection for this service since its registration with CQC. This key question has been rated 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 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 we spoke with were positive about the culture, on the day of the assessment, we observed staff interacting respectfully and positively with one another and with patients, which demonstrated a supportive working environment.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the Primary Care Network (PCN) 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 voice would be heard.

The practice had established Freedom to Speak up arrangements with the local PCN. The service had an open culture where staff felt confident to speak up if they had concerns or ideas for improvement. Staff told us they were listened to and felt safe raising issues without fear of negative consequences. Leaders promoted honesty and transparency, encouraging staff to share concerns early so they could be addressed quickly. There were clear policies in place for speaking up, and staff knew how to access them if they wanted to raise a concern formally. Regular team meetings and supervision sessions gave further opportunities for staff to talk openly about their experiences.

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

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, and the wellbeing of staff was supported.

The service encouraged a culture of equality, diversity, and inclusion. Leaders ensured staff were recruited fairly and valued for their skills, knowledge, and personal qualities, regardless of background or personal circumstances.

Training in equality and diversity was provided, and staff understood the importance of creating an inclusive environment both within the workplace and in the care they delivered. Staff said the service encouraged openness and respected individual differences, which helped build a positive and supportive team culture.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

While leaders and managers were supportive and staff understood their roles, some governance arrangements were not consistently effective in providing assurance. These included systems for summarising medical records, maintaining staff training and personnel files and infection prevention and control (IPC) compliance.

The provider was responsive to feedback and committed to implementing improvements following the inspection. The provider was able to evidence changes to ensure effective oversight for the future and assured us the changes would be embedded and sustained.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services. This focussed on the appointment system. We found the practice had encouraged staff members to further educate themselves including a secretary who had undertaken a leadership course and a health care assistant who was working on their nurse qualification.

However, we found that the provider needed to strengthen their quality assurance systems to ensure they identified learning and improvement as we found gaps in some processes during the inspection.