The Northenden 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

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.

Overall, leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. However, we found that aspects of staff management and the overall organisation were not sufficiently effective and required improvement.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed.

We found breaches of regulation in relation to safe care and treatment, good governance, and staffing. We have asked the provider for an action plan in response to the concerns found at this assessment.

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.

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. 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 engaged in developing 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 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. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

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

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.

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.

Whilst the provider had some governance systems in place, these were not monitored and there was a lack of governance oversight in regard to medicines management and monitoring people with long term conditions.

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.

However, we found that despite staff being offered opportunities to complete mandatory training, there was a lack of oversight and monitoring of mandatory learning, with the many of clinical and non-clinical staff being out of date in many mandatory learning modules.

The service did not ensure that important documentation was centrally accessible to staff, and at the time of the inspection, key safeguarding information could not be accessed, which limited staff’s ability to respond effectively to risks.

Immediately following the inspection, the provider had taken steps to improve governance and were providing CQC with updates and an action plan to evidence action taken.
 

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access at weekends and some evenings, and flu and covid vaccination programmes.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service did not demonstrate a culture that supported effective continuing professional development or ensured staff remained up to date with mandatory training. Staff reported being too busy to complete essential learning, which indicated a lack of effective management oversight and an organisational culture that did not prioritise ongoing competence or safe practice.