Practice Plus Group Hospital - Emersons Green

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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

This means 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 we rated this key question Good. At this assessment the rating has remained Good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

Quality Statement Score: 3

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. The evidence showed a good standard. 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.

There were a shared vision, strategy and culture based on transparency, equality, diversity, inclusion and respect for human rights. Leaders demonstrated an understanding of the challenges and needs of people using services, staff and the wider sector, and used this understanding to support service delivery.

We spoke with 3 members of staff within the department. Staff understood the provider’s vision and values and were able to describe how these were reflected in their day-to-day work. We saw posters displayed throughout the service which outlined the provider’s leadership charter, vision and values.

We reviewed the provider’s induction and familiarisation pack for new starters, which included information about the organisation’s vision and values.

Staff told us they were aware of the provider’s vision and felt senior leaders were visible and approachable within the hospital. Staff said they felt listened to and described the departmental manager as having an ‘open-door’ policy.

Senior leaders told us the hospital had implemented a ‘You Said, We Did’ programme to respond to staff feedback. They had also introduced a staff forum and restructured the Freedom to Speak Up arrangements to better reflect the range of professional disciplines across the hospital. In addition, leaders had introduced a ‘Coffee with the Hospital Director’ initiative, providing staff with opportunities to meet and speak directly with the hospital director.

Quality Statement Score: 3

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. 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.

Leaders were knowledgeable about issues and priorities relating to the quality of services. They had access to support and development opportunities appropriate to their roles and understood when to seek additional support or independent scrutiny.

We interviewed senior leaders from both the department and the hospital. Leaders demonstrated a good understanding of the services they managed and were able to clearly explain how teams worked together to deliver high-quality care and treatment.

Leaders had the skills, knowledge and experience to carry out their roles effectively. Staff told us leaders were visible within the service and approachable for both patients and staff.

Leaders and staff described a range of development opportunities available within the organisation, including access to specialist training to support staff in their roles and career development.

Senior leaders told us they attended provider governance meetings and contributed to discussions about service development and quality improvement within the department.

Records we reviewed, including governance meeting minutes and departmental meeting minutes, supported what leaders and staff told us.

Quality Statement Score: 3

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up, and their voices would be heard.

Leaders were open to feedback and staff felt supported to speak up and raise concerns.

Leaders told us the Freedom to Speak Up arrangements had recently been restructured to provide greater representation across departments and professional groups. Leaders said they had recognised that the previous model, where Champions were members of the senior management team, may have discouraged some staff from raising concerns. The revised structure was intended to improve accessibility and encourage staff to speak up. Staff told us that there was also a staff helpline that offered support.

Minutes from outpatient departmental meetings showed staff discussed feedback from people using the service and identified actions in response where improvements were required.

Quality Statement Score: 3

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. The evidence showed a good standard. 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.

There were business continuity plans to support the service in the event of emergencies or natural disasters, including adverse weather events. Staff were aware of these plans and described their roles and responsibilities in the event of an emergency.

The 2024/25 Practice Plus Group quality account entry for Emersons Green reported the setting up of an equality, diversity and inclusion (EDI) Committee This meets quarterly. The hospital had appointed an EDI lead. The new starter orientation programme included a module on equality and diversity, together with mandatory eLearning module titled ‘equality, diversity and human rights’, records show 94% of staff had completed the module.

The staff induction checklist required line managers to identify and consider any reasonable adjustments or specific requirements new starters may have in relation to working arrangements. This included personal circumstances, such as caring responsibilities or health needs.

Quality Statement Score: 3

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. The evidence showed a good standard. 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.

Staff and leaders were open and transparent and worked collaboratively with external organisations and partner agencies to support patient care and service delivery.

Leaders had clearly defined roles, responsibilities and accountability arrangements. Governance systems were effective in supporting the delivery of good-quality, sustainable care and treatment. Leaders used governance and oversight processes to identify areas for improvement and develop plans to address these.

There was a clear structure for discussions at departmental and hospital meetings. This ensured essential information, including learning from incidents and complaints, was shared and discussed with staff. Staff we spoke with told us that the 3 top risks to the department were listed on the staff noticeboard as a memory aid.

Staff had implemented learning and recommendations, incidents and complaints to improve the quality and safety of care.

Staff carried out and participated in local clinical audits. Audit activity provided assurance about the quality of care and staff acted on findings when improvements were identified.

Staff understood how to work effectively with other teams within the organisation and with external partners to meet patients’ needs.

Staff we spoke with demonstrated an awareness of the key risks facing the department. Departmental risks were a standing agenda item at team meetings, and the concerns raised by staff reflected those recorded on the risk register.

The service had business continuity arrangements for emergencies, including adverse weather and outbreaks of infectious illness. These were outlined within the business continuity plan.

The service used electronic systems to collect departmental data. Staff told us these systems did not place an undue burden on frontline teams.

Staff had access to the equipment and information technology needed to carry out their roles effectively.

Information governance systems supported the secure management of patient information and the confidentiality of patient records. Staff received mandatory training in information governance and data security. Training compliance was reported as 90%.

Leaders had access to information to support effective oversight and management of the service. This included information relating to service performance, staffing and patient care. We reviewed 2 monthly quality review meeting slide decks, which included updates on risks, training compliance, incidents and learning outcomes. Information was presented in an accessible format, was timely and accurate, identified areas for improvement and was escalated through the hospital’s governance structures.

Quality Statement Score: 3

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard. 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.

Staff and leaders were open and transparent and worked collaboratively with external stakeholders and partner organisations to support the delivery of care.

Senior leaders told us they met regularly with representatives from the Integrated Care Board (ICB) to discuss service delivery and local healthcare priorities. Department leaders also maintained links with external stakeholders, including local GPs, and provided patients with information about community-based support services.

Patients and staff had opportunities to share feedback about the service with senior leaders and commissioners. Patients could also request a rapid review of their care if they were worried about their condition deteriorating, in line with the provider’s implementation of Martha’s Rule. Martha's Rule is an NHS patient safety initiative that gives patients, families, carers, and staff 24/7 access to a rapid, independent review if a patient's condition is worsening and concerns feel unheard.

Quality Statement Score: 3

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 3. The evidence showed a good standard. 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.

Leaders promoted a culture of continuous learning, improvement and innovation across the outpatient’s department. Staff were encouraged to identify and implement improvements to support equitable access, positive experiences and better outcomes for patients.

Staff told us they were given the time and support to develop ideas for service improvement and innovation. They described how this had led to changes in the way care was delivered. Staff also told us they were encouraged to undertake additional specialist training relevant to their roles, including training in pre-operative assessment.

Leaders told us there were no active research projects taking place at the hospital at the time of our inspection.

The hospital participated in national clinical audit programmes. The provider’s 2024/25 Quality Account reported that the hospital had achieved a Silver Award from the National Joint Registry in recognition of the quality and completeness of data submitted for the annual data quality audit.

The hospital director told us they had identified areas for improvement within the service. They described plans to implement a recognised quality improvement methodology, for which they had received training, to support service development and drive improvements across the hospital, including within outpatient services.