Holbrooks Health Team

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 requires improvement. At this assessment, the rating remains the same. Previous concerns related to staff appraisals, whistleblowing policy and Patient Group Direction. On this assessment we found the practice had improved in these areas. However, there were shortfalls in other areas.

The service was in breach of legal regulation in relation to Regulation 17 good governance.

This service scored 62 (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 had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. Practice leaders were aware of required updates to the premises and were in discussion with the landlord.

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 and credibility to lead. They did so with integrity, openness and honesty.

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.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

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.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued. Staff gave examples of the practice supporting them with professional development and career progression.

Staff had clear roles, responsibilities, and some governance systems to deliver good quality sustainable care, treatment and support. The service did not have clear responsibilities, roles, 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. Governance processes were mostly well-established, with accessible policies and procedures. Leaders held regular meetings to discuss risk, performance and operational management of the practice.

Regular searches of the clinical record system were undertaken to identify patient needs and ensure these were being met. However, our review of clinical records showed that this was not always effective. Oversight of some safety netting processes needed strengthening, there was a lack of oversight regarding cleaning schedules and inconsistencies in record keeping of staff files. As a result, we were not assured that governance systems were consistently effective. Whilst the provider took action, we cannot be assured that newly implemented systems will be sustained and embedded.

Staff we spoke with knew who the relevant lead person was for areas such as safeguarding, infection control and significant events monitoring. Staff took patient confidentiality and information security seriously. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any learning and actions arising from these meetings and ensured they shared these with staff. Managers met with staff regularly to complete appraisals and performance reviews.

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 collaborated for improvement.

The provider worked with other practices within their primary care network (PCN) to offer extended access, and flu and covid vaccination programmes.

The practice worked with their Patient Participation Group (PPG) to proactively reach out to the Black, Asian and Minority Ethnic (BAME) community to improve uptake in cervical screening and childhood immunisations.

The service had a focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. There were established processes to ensure that learning happened when things went wrong, and from examples of good practice. All staff were encouraged to put forward and test out new ways of working. They actively contributed to safe, effective practice research and training. Leaders actively invested time to listen and engage with staff at all levels. We received positive comments from staff who felt leaders welcomed their feedback.

The provider had developed a quality improvement plan and an action plan informed by data from the national GP patient survey, focusing on staffing and the appointment system. However, the overall quality system was not sufficiently effective in identifying risks or ensuring that learning was captured and used to drive sustained improvement.