Hollins Grove Surgery

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 remains the same.

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 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. All staff were able to contribute to the development of the practice vision and strategy, which was kept under review. The practice had an improvement plan in place that was monitored and they worked with other services to assess future challenges.

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.

Most staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network 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. Not all the staff we received feedback from knew who the Freedom to Speak Up Guardian was, but they all stated they were able to raise concerns within the practice.

The practice did not have established Freedom to Speak up arrangements with other practices in the primary care network. The whistleblowing policy stated regulators could be contacted if people wished to do so.

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. Policies and procedures to promote diversity and equality 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 service was in the process of making changes to ensure there were clear responsibilities, roles, systems of accountability and good governance. Governance was being assessed and amended as appropriate. This included a review of all policies to ensure they were specific to this service; they were previously shared with another GP practice.

Most staff also worked at another GP practice in a different town, and the service was in the process of ensuring staff were clear about their roles for the different places they worked.

Meetings took place where learning from significant events and complaints were discussed. Other than the provider, GPs at the service were long-term locum GPs. They did not attend meetings so information about the practice, including learning, was not formally shared. However, the provider informed us they were in the process of assessing this with a view to holding meetings that all clinicians could attend.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. They worked very closely with another GP practice in a different town.

The practice did not have a patient participation group (PPG). The provider told us they had a couple of patients interested in joining a group and they were in the process of arranging a meeting.

The service had a focus on learning and improvement after it had been identified that some aspects of the service needed to be developed. They had a documented plan in place to monitor areas where improvement was required, and they received support from partner agencies for advice on this. All staff were involved in the improvement plan.