Haden Vale Medical 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 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 as Good. At this assessment, the rating has changed to Requires Improvement.

The service was in breach of legal regulation in relation to:

• Governance processes were ineffective in assessing, monitoring and mitigating the risks relating to the health, safety and welfare of people.

We found governance processes needed improvement to ensure there were safe systems in place. Processes for the management of medicines required strengthening to provide the appropriate care and treatment to people. Infection control systems were not effective in mitigating risks and there were no effective processes to monitor the skills and knowledge of staff so people had safe care and treatment.

Leaders and staff shared a clear vision and culture in listening and mutual trust. Staff told us the leadership team were supportive. Staff reported feeling empowered to provide feedback and described a workplace culture that promoted equality and was free from bullying or harassment.

This service scored 64 (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 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.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. To increase patient satisfaction in relation to access, the provider had installed a call back option on the telephone system and had recently employed an advanced nurse practitioner to support the clinical team. Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care. Team members highlighted effective communication and stated that they felt included in decision making processes relating to the service.

The practice had a realistic strategy and supporting business plans to achieve sustainability, this included employing more staff and improving access. The leadership team were committed to working collaboratively with their PCN and the local community to educate and achieve positive outcomes for their patient population.

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

There was an open culture, however learning within the practice needed to be expanded to ensure all staff were included in opportunities to improve the quality of services and mitigate future risks. Regular meetings were held with staff within their departments and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

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, but clinical oversight and supervision needed further improvement.

We found a lack of clinical oversight and supervision to ensure staff were carrying out their roles effectively and the leadership team were aware of the skills and knowledge of the staff they had employed. Staff were carrying out clinical reviews without the appropriate knowledge, experience or awareness of clinical guidelines. We were unable to gain assurances that the leaders had an effective process in place to monitor all staff carrying out clinical duties.

The practice was a teaching practice for medical registrars and in the past 12 months had started to provide a teaching environment for medical students.

Staff told us leaders in the practice was approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN 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.

The practice had established Freedom to Speak up arrangements with other practices in the PCN. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

There were regular meetings held with staff and there was a freedom to speak up guardian in place.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were well supported and felt able to ask for advice. The leadership team had implemented a stress risk assessment to identify any concerns staff may have with their workload and to provide additional support if required. Staff told us they were encouraged to develop within their roles and training opportunities were available. The leadership team had recently implemented a monthly shining star award to promote staff’s contribution to practice achievements. This provided opportunities for staff to feedback on their colleagues’ innovative approach to the care and support of both patients and staff.

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

We found the practice was unable to demonstrate that there was clear oversight of governance arrangements to ensure risks to patients were considered, managed and mitigated appropriately. For example, systems to ensure the regular monitoring of people on high-risk medicines and people with long term conditions. We also found the system in place for acting on safety alerts and alerts on clinical records was not effective. Following the assessment, we received evidence to demonstrate that a review of the clinical findings had been completed. Risks in relation to infection control processes were identified; however, a risk assessment had been undertaken to identify potential risks and the infection control policy was adhered too by all staff. We found a lack of clinical oversight and supervision to ensure staff were carrying out their roles effectively. We identified staff were carrying out clinical reviews without the appropriate knowledge, experience or awareness of clinical guidelines. We were unable to gain assurances that the leaders had an effective process in place to monitor all staff carrying out clinical duties.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Managers encouraged staff to raise concerns when things went wrong. We found meetings with the whole practice team were not held on a regular basis and we had no assurances that the learning was discussed and shared with all departments. Staff told us learning was shared on an individual basis with the person concerned, but there was no structured process in place. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The practice had a significant events policy and a reporting form was in place, which was accessible to all staff members. We found on speaking with some staff they were unaware a reporting form was available and would report directly to the management team any concerns they identified.

The practice had a system in place to record and investigate complaints. The practice had a complaints procedure in place. We reviewed a random sample of complaints and found the provider had responded in a timely manner and had offered apologies to people. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. Feedback and information were available in the practice and on their website. The outcome of the GP National Patient survey showed people had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

The service focused on improvement across the organisation and local system, however the sharing of learning with the whole team needed to be strengthened to ensure all staff were aware of what actions had been taken and how improvements had been implemented.

The practice had completed a telephone audit in September 2024 to understand where improvements were needed. This had highlighted specific days were busier than others and administration requests were also making the phone lines busy. To improve telephone access, a call back facility had been implemented for people to leave a message and a member of staff would contact them. Also pre-bookable appointments were reduced on the days that were busier than usual to provide more on the day appointments. People were also being encouraged to use the NHS App for prescription requests and an online form was now available through the practice website for administration and non-urgent medical requests.