Dearne Valley 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

At our previous assessment in March 2016, we rated the practice as Good for providing well-led services. At this assessment we have rated the practice as Good.

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.

We found that some governance arrangements requiring strengthening, particularly around safeguarding procedures, and managing and dealing with MHRA alerts. Following the assessment we received an action plan detailing how governance processes would be strengthened.

This service scored 71 (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.

Staff feedback we received was overwhelmingly positive about the culture of the practice. Staff told us they felt involved and were able to contribute to forming the direction and culture of the practice. Staff described very strong relations between peers and supervisors. We saw that there was a stable workforce in place and staff turnover was very low. Feedback provided to us from staff showed how they had been involved in developing the practice’s mission statement and that this was upheld across the practice.

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 found that leaders had created an open culture where staff felt comfortable to raise concerns and speak up when required. We saw that leaders had recently completed a staff wellbeing survey, from 21 responses 100% of staff said they felt supported and valued at work.

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. Following this assessment the provider had plans in place to share learning with the other members of their primary care network.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Through staff feedback received we saw that all staff where able to identify who their Freedom to Speak up guardian was. The practice had established Freedom to Speak up arrangements with a neighbouring practice in the primary care network. One of the senior leaders acted as a Freedom to Speak up guardian for a neighbouring practice. Staff were aware of how to raise concerns and were supported by the management team to do so.

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.

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. We saw that governance processes around the management of MHRA alerts needed strengthening as remote clinical searches identified that these were not always followed as they should have been.

Managerial oversight of safeguarding procedures also required strengthening. We found that the practice was not reconciling their safeguarding list with the local authority, which meant that potentially vulnerable patients were not being coded appropriately.Following the assessment the provider had engaged with their local authority however they found that they did not have processes in place to align their safeguarding register with the practice.

We found that managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Following this assessment these meetings were improved to continually review MHRA alerts. 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. Following this assessment the practice was arranging a learning lessons event with other members of their primary care network

We saw examples of how the practice regularly gathered feedback from patients in the form of questionnaires and through text messages following appointments. We saw that from 846 responses from patients, 68% of patients rated the service they had received as either 4 or 5 stars. The practice also used social media to engage with patients and to gather feedback from them.

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 contribute to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services. An example we saw of this was a new mental health template which was used for triaging patients with mental health problems. Patients who required an appointment due to their mental health were taken through a series of questions which produced a score. If their scores indicated, they required an emergency appointment they would be offered one that day. If the score was moderate, they would be offered an appointment within 2 days. If the score was low, they were offered a routine appointment. Feedback from staff and patients about this new template were positive. All staff were encouraged to put forward and test out new ways of working.