Urmston Group 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy.

Feedback from both leaders and staff described a positive and supportive culture. Staff described good teamwork, strong communication and a well-organised environment. Communication was facilitated through weekly newsletters, email updates and regular team meetings.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service mostly had clear responsibilities, roles, systems of accountability and governance arrangements. However, we identified some areas where governance oversight was not fully effective.

Leaders used governance systems to manage and deliver care, treatment and support, acting on information about risk, performance and outcomes. Staff we spoke with understood their individual roles and responsibilities and described leaders as visible, supportive and approachable. Leaders met regularly with staff to discuss performance, incidents, risks and service developments, and staff had access to policies and procedures through the practice's governance systems.

The practice had systems in place to monitor quality and drive improvement, including audits, and regular meetings.

However, governance arrangements had not always ensured risks were identified and managed effectively. For example, fire safety arrangements were not sufficiently robust. The fire risk assessment had been completed internally and did not identify a number of issues found during our inspection, including the absence of a fire evacuation notice and a written fire evacuation plan. Incident reporting processes were not always fully aligned with regulatory requirements, with one incident lacking evidence of Duty of Candour processes or consideration of a statutory CQC notification. The practice also did not have a formalised policy for incident reporting.

After the inspection the practice sent in some additional evidence to demonstrate that all the issues had been resolved and we were satisfied with the prompt action taken by the provider.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.