Shirley Health Partnership

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 following its relocation to new premises This key question has been rated as Good.

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 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 told us there was a positive team culture and they felt supported by GPs and senior leaders. They told us they were able to contribute to discussions about service improvements, incidents and complaints. All staff we spoke with were proud to work for the service. The service was keen to continue to support and develop its staff. For example, nurses, who had expressed an interest, had been supported to become non-medical prescribers demonstrating a culture of investing in workforce.

Positive learning culture was demonstrated through meeting minutes which showed that performance, incidents, feedback and complaints were routinely discussed.

There were established and effective processes and systems for leaders to share their vision, practical experience and support with colleagues. This was achieved formally through governance meetings and clinical discussions which the service had scheduled and shared with staff.

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 had access to line managers within their departments and told us leaders in the service were approachable. Each department within the service had a designated GP lead who concerns could be escalated to. Staff also told us leaders modelled the values of the service.

We saw the leadership team worked with other members in 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 voice would be heard. Each department had a designated GP lead who concerns could be escalated to.

The service had established Freedom to Speak up arrangements with the local integrated care board (ICB). Staff were aware of how to raise concerns.

The service had a zero-tolerance policy in relation to the abuse of staff, with systems to protect people and minimise the likelihood of reoccurrence.

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.

Health and safety risk assessments, including Display Screen Equipment (DSE) assessments, were carried out in line with the Health and Safety (Display Screen Equipment) Regulations 1992. These assessments ensured workstations were ergonomically designed to support staff wellbeing, with adjustments such as screen adaptors, ergonomic chairs, or standing desks provided where needed. Flexible working arrangements, including varied shift patterns, were also offered to support reasonable adjustments and leadership used occupational health services to support with this where necessary.

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

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff had yearly appraisals and met more regularly for informal check-ins. The service had established governance processes that were appropriate for their service; however, oversight of mandatory training had not consistently ensured compliance. The provider had identified this and initiated improvements, including reviewing processes with managers and partners, to strengthen oversight and accountability. The service introduced more formal protected time within workforce planning for staff to complete training, demonstrating a proactive approach to improvement.

Staff could access all required policies and procedures via practice index the services chosen governance system. Leaders held regular service meetings with staff, during which they discussed clinical concerns and emerging risks. Actions arising from these meetings were recorded and shared with staff. Staff took confidentiality and information security seriously.

Leaders demonstrated a forward planning approach to workforce sustainability, with clear nursing plans in place that anticipated future service needs, including staff development, changes in working patterns, and succession planning to support continuity of care.

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 service worked with other services within their primary care network (PCN) to offer or utilise extended access and social prescribers. The service also hosted other services within the PCN, such as midwives and social prescribers allowing them to base themselves at the premises. Staff adjusted to improve coordination of their service with community healthcare services, including through multi-disciplinary team (MDT) meetings centred on the care of those using 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 service had moved to a new premises in 2024 which was purpose-built and the service felt it met the needs of the people using the service better.

The service has a plan to introduce a new triage system to improve access by enabling people to book appointments based on clinical need, supported by oversight from the duty triage team and arrangements to continue to support people attending in person.

All staff were encouraged to put forward and test out new ways of working, for example, staff had made suggestions on the format of safeguarding meetings and changes were made to better support them in their role in safeguarding people. For example, the service had lengthened its safeguarding meetings to allow staff to bring cases to the meeting for detailed discussion and reflection. Staff told us that this had empowered them to have more confidence in assessing and reporting safeguarding concerns.