Pennine Drive 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

At our last assessment, we rated this key question as good. At this assessment, the rating has changed and is now rated as requires improvement.

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open and fair culture. We found that whilst the practice had assurance and governance policies in place, improvements were needed in systems and processes. In particular, improvement in: communication with staff members; employment checks; completion of staff appraisals; cold chain management and monitoring of emergency equipment; Patient Group Directions (PGDs); monitoring and prescribing of some high-risk medicines; patient safety alerts; management of some long-term conditions; quality outcome audits; and oversight of mandatory staff training. We found breaches of regulation in relation to well-led services.

This service scored 61 (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.

The practice had a mission statement which stated that the practice had a clear vision and strategy to deliver high quality care (although this strategy was not outlined in the mission statement) and promote good outcomes for patients and staff in an efficient safe and caring environment. The mission statement detailed that this included a well thought through governance framework, a developing leadership strategy, a culture that supported learning and innovation, team-based working, high levels of staff engagement and patient and carer engagement. Leaders told us that the practice placed patient centred care at the core of its values. They informed us that the vision and strategy was reviewed regularly. Staff members were made aware of the vision and strategy during the induction process. Staff members we spoke with were fully conversant with the practice’s mission and values and evidenced their understanding and role in achieving this. Leaders told us that there was an open and inclusive culture at the practice, and this was confirmed by staff members we spoke with. Staff told us that they understood the importance of person-centred care and the provision of an efficient service.

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.

The practice had inclusive leaders who understood the context in which the surgery delivered care, treatment and support. Leaders were supportive of their staff to deliver patient care that was compassionate and showed the ethos of the practice. We received feedback in staff interviews that suggested there was a positive relationship between staff, management and clinical staff, with staff reporting that they felt supported. Staff members told us they felt comfortable and confident in raising any concerns with leaders. Staff had access to training and development, however, it could be beneficial for staff members to discuss this at regular appraisals. The practice had contact with local practices and was involved in liaising with the PCN in relation to virtual cancer wellbeing clinics, a PCN project.

People did not always feel they could speak up and that their voice would be heard.

Staff members we spoke with at the practice told us management fostered a culture where people felt they could speak up and that their voices would be heard. The practice had a freedom to speak up policy which was available for staff to view on the shared drive and in paper format. The practice told us that new staff members would be made aware of the whistleblowing policy during the induction process. We did not see evidence in the training records that all staff had completed whistleblowing training. The practice had a named freedom to speak up guardian.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Reasonable adjustments had been made to ensure all staff were valued. The practice gave examples of where health and safety risk assessments had been considered, and new office chairs had been purchased where required. Staff members were required to complete training on equality and diversity. The practice had policies and procedures in place to promote workforce equality, diversity and inclusion. Staff members had access to continual professional development and mentorship.

During our review of staff files, we noted that staff appraisals were not being completed consistently and the performance appraisal policy and procedure was not always being followed. Staff told us that they would like to have appraisals. Staff also told us that they would like to have practice meetings. We provided feedback to the practice that appraisals and regular practice meetings would provide opportunities for consistency of messaging and learning opportunities could be explored. The practice’s shared direction and culture could be explored and cascaded at these opportunities for engagement with staff to ensure a consistent approach.

The practice did not always have clear systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Although the practice had assurance and governance policies in place, this assessment found improvements in systems and process were required for managing risks in the following areas: communication with staff members including opportunities for learning through practice meetings; staff training was up to date and to the correct level; pre-employment checks were completed and recorded for all staff members; appraisals for all staff members; cold chain management and monitoring of emergency equipment; ensuring Patient Group Directions (PGDs) were signed consistently; effective monitoring and prescribing of some high-risk medicines; actioning of patient safety alerts; effective management of patients with some long-term conditions; and effective quality outcome audits carried out which included reflections on procedures and how outcomes might be improved.

We noted that oversight of training was not always consistent, and we saw gaps in staff training records in relation to basic life support training, fire safety training, Mental Capacity Act training, sepsis awareness training and safeguarding adults and children training to the appropriate level. We noted that several policies and procedures had been recently implemented and compliance with these would be checked at our next inspection. At the time of our inspection, the practice was not aware of the national GP patient survey and consequently had not reviewed the results of the published survey or devised an action plan to address areas of poor feedback. The practice results in some areas of feedback fell below the local GP average and national average scores.

The practice collaborated with other healthcare professionals in partnership to provide care for the patient population. There was a patient participation group (PPG) who had met once at the time of our inspection and were due to meet again immediately following. The PPG represented the view of people using the service. The practice had informed PPG members that it would like more regular meetings and input from the PPG. The practice interacted with the PCN and held multidisciplinary meetings to discuss and improve outcomes of patients with complex needs. The practice collaborated with stakeholders and held meetings engaging with palliative care teams and district nurses.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff members told us leaders supported them in their development. Staff members were encouraged to suggest improvement ideas and had regular one to one meetings with leaders. Learning from significant events and complaints was disseminated to staff on an ad hoc basis. Staff members provided us with feedback they would benefit from regular practice meetings and appraisals which would assist with embedding learning and continuous improvement.