Kirkham Health Centre

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• 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and 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 is in breach of legal regulations around 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, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

Staff had been involved in the contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years and worked with partner agencies to address these challenges. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although the service had defined responsibilities and roles, their accountability and governance systems were not effective. Systems to provide assurance of safe staffing were not effective such as recruitment records, training records and oversight were not effective. Furthermore, it was not always evident that environmental and health and safety risk assessments such as fire, legionella and infection prevention and control were acted upon in a timely way or that actions or risks had been followed up. Some aspects of risk assessments were noted to require immediate action or within one month, but some of these had not been completed. This was in part due to limitations in what could be achieved given the age and condition of the building and environmental challenges. Managers also reported that they did not have enough space to deliver the service they aspired to deliver. They had sought funding to make some improvements to the environment, but found some aspects that required attention were not achievable or would required significant investment and cause disruption to service delivery.

Leaders held regular meetings with staff, such as team meetings, clinical governance, partners and senior leadership team meetings, agendas were prepared in advance and minutes were taken and shared. However, it was not always clear from these minutes that actions had been completed and closed. Staff could access all required policies and procedures, however the system for reviewing and revising such policies was not clear. The practice recruitment policy did not presently reflect guidance and legislation, but the practice were working to make this compliant.

All staff we spoke with were clear on their individual roles and responsibilities, they took confidentiality and information security seriously, and submitted data and notifications to external agencies as required. Leaders were supportive and visible and staff reported they were happy in their work and had trust and confidence in leaders. They reported notable improvements in the practice since the current practice manager had took up post. We found that leaders demonstrated the capacity and commitment to further improve the practice.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.