Stephenson Park Health Group

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 75 (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 leaders at the practice spoke positively about moving forward, their direction and culture and about making improvements to the service.

Staff reported there was an open and honest culture within the practice, and they felt able to raise concerns without fear of retribution.

The practice informed us that they actively encouraged staff involvement through initiatives such as two annual "away days" held in the past two years, which aimed to empower staff and involve them in shaping the future of the practice. However, the practice did not have a written business plan in place, although one was currently in development.

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.

Staff told us leaders in the practice were approachable and responded to any concerns raised. 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.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network.

Of the staff who responded to the staff feedback questionnaire, 88% reported that they knew who the Freedom to Speak Up Guardian was and were aware of how to raise concerns.

The service valued diversity in their workforce. They work 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. We saw senior leaders had addressed concerns related to discrimination. The practice had implemented several reasonable adjustments to support staff. This included providing staff with ergonomically friendly equipment. Maternity-related needs were also accommodated by allowing staff to attend medical appointments.

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.

At times, the governance processes in place did not ensure that patients were monitored and reviewed in accordance with guidelines. There was no written business plan in place, although one was under development. Additionally, regular appraisals were not conducted in accordance with their policy, and 1 staff member did not fully understand their role and responsibilities.There had also been no oversight of staff vaccinations, as administrative staff had not been asked to provide their vaccination status.

However, leaders and managers provided support to staff and had established governance processes that were appropriate for the service. Staff had access to all necessary policies and procedures. Managers held regular practice meetings with staff to discuss clinical concerns and emerging risks. Staff took patient confidentiality and information security seriously.

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 to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including established meetings centred on the care of those at higher risk of hospital admission.

There was an active patient participation group (PPG) who represented the views of people using the service. Although the group was small, the practice advertised for PPG members on their website. However, the PPG had not met so far this year.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

As part of a quality improvement initiative, the practice worked collaboratively across the Primary Care Network (PCN) to address demand and capacity challenges, particularly around urgent access in line with the Quality and Outcomes Framework (QOF) access indicator. A variety of tools were implemented to better understand and respond to demand, including analysis of patient feedback, telephone activity, and 111 data. Appointment systems were adjusted to align with peak times of demand, and a trial with Northumbria Healthcare tested direct booking from urgent care into primary care to further streamline access.

The practice had actively engaged in research projects, reflecting a strong commitment to advancing healthcare knowledge and improving clinical practice. A partner at the practice held a contract with the National Institute for Health and Care Research (NIHR) and served as the Primary Care Engagement Lead. Summaries of recent research involvement included the OPAL study, focused on optimal prescribing of Levothyroxine for patients with hypothyroidism, participation in the PANORAMIC trial, a national platform study led by the University of Oxford, evaluating the effectiveness of novel antiviral treatments for COVID-19 in community settings. In addition, the practice contributed to a study focused on highlighting alcohol use during medication reviews. This study aimed to find ways of improving how pharmacists discussed patients’ health and wellbeing during medication reviews, including initiating more effective conversations around alcohol consumption.

Leaders told us they actively supported staff development through a range of structured opportunities and career pathways. The practice was a teaching and training site, hosting medical students from Newcastle and Sunderland Universities. Career progression was encouraged, with 1 staff member supported to advance from Healthcare Assistant to Nurse Associate and then qualifying as a Registered General Nurse (RGN). In addition, 2 other staff members were currently being supported on the pathway to becoming Nurse Associates. The practice had also provided a career development route for 3 administrative staff members to train as Pharmacy Technicians.