Burnley 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

The practice did not have an established and embedded culture of continuous improvement and quality assurance. The practice did not have effective systems to assess, monitor and improve the quality and safety of the services they provided. They did not have systems and processes that enabled them to identify and assess risks to the health and safety of people who used the service or how they might improve. However, leaders and staff had a shared vision and culture based on listening, learning and trust and were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were mostly content in their roles. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.

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 practice had a shared vision, strategy and culture in place. Their vision was “Burnley Group Practice aims to offer patients with the highest quality of primary health care.” Staff were familiar with this and demonstrated this in their work.

The practice had a business development plan in place and a vision for what it wanted to achieve in the coming years. This set out the steps it wanted to achieve to enable sustainability and build upon aims to provide high quality healthcare to their patients. They had aspirational plans and ideas they wanted to pursue to enhance the service to patients and improve staff engagement and wellbeing.

The practice 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 and with the best interests of patients and staff in mind.

Staff told us leaders in the practice were approachable and responded to any concerns raised. They provided examples of support provided and how managers involved them and listened to their ideas. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked together with organisations and commissioners and were engaged in the development of primary care services within the local area.

Although we found areas of concern during the inspection, leaders were quick to address them and implement solutions to the issues raised with them.

The practice had a Freedom to Speak Up (FTSU) policy in place. The practice had a designated FTSU guardian that staff could contact if there were any concerns. Managers were also available and receptive to hearing about the concerns staff may have had. The practice promoted a positive and supportive culture where people felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns, contribute ideas and give feedback. Managers had an open-door policy for all staff.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff.

The practice had clear responsibilities, roles, and systems of accountability. However, systems were not always in place to support the management and delivery of high-quality, sustainable care, treatment and support.

They did not always employ tools to extract the best information about risk, performance and outcomes, to enable them to understand their own issues and how they could improve. The practice had not established governance processes that were appropriate for their service.

Managers met with staff regularly but the majority of staff had incomplete appraisals and performance reviews. There was a lack of oversight of staff competence as there were gaps in managing clinical supervision and support as records were not kept and this was informal. There was a lack of record keeping regarding retention of key information relating to recruitment records and induction records. Minutes of meeting were not always sufficiently detailed to enable staff to understand the discussions and decisions that had taken place. It was not always evident how outcomes and actions from meetings or audits were followed up, actioned and closed. Record keeping in relation to prescription security did not provide adequate assurance of their safekeeping and protection from misappropriation. Systems to oversee workflow and ensure this was processed in an appropriate and timely way was not in place.

Policies and procedures were out of date or missing for some key processes such as recruitment, appraisals, infection prevention and control. They did not have a reliable system for reviewing, updating and archiving polices, procedures and standard operating procedures.

However, leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers held regular practice meetings and learning sessions, and most staff reported feeling valued and respected. Staff took patient confidentiality and information security seriously.

During the inspection, the practice managers and leadership teams were positive and engaged and described how they would take steps to improve the identified areas of concern and stated they would work to improve governance processes.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The practice worked with other practices within their primary care network to offer extended access. Staff had made adjustments to improve coordination of their service with community healthcare services.

The practice had an active patient participation group, which met regularly. We saw that the practice were responsive to the merits of this group and positively engaged with them.

The practice did not always have systems and tools in place to support continuous learning, innovation and improvement across the organisation. They did not always proactively identify areas of concern or areas where they could improve, due to an absence of quality assurance and performance measurement processes. There was evidence that they reacted if an issue occurred, but did not proactively undertake continuous monitoring of their processes to ensure they were working effectively or assess ways they could improve based on by examining their own performance. They did not actively contribute to safe, effective practice and research through an established annual clinical audit programme.

The practice did not have an effective quality assurance process or quality audits in place. We asked the practice to provide us with evidence that the quality of treatment and services had been monitored within the last 12 months, including 2 completed clinical audit cycles. The practice was unable to provide us with such because they did not have one in place. The practice supplied audits completed in connection with the education of junior and trainee doctors rather than as part of an established quality improvement strategy.

The practice did not have a system of oversight or audit of clinical consultations, record keeping or prescribing for clinical staff, including advanced care practitioners. Whilst supervision and support was in place, this did not extend to dip sampling of consultations and the quality of record keeping, however they did participate in the Integrated Care Board review and evaluation of prescribing practice.

Following the inspection, the practice stated they would work to implement a clinical and non-clinical audit quality monitoring programme.