Lawrence Hill Health Centre

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 practice 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. This was due to improvements being needed in the oversight of governance arrangements, to ensure systems and processes were effective.

The practice was in breach of legal regulation in relation to good governance.

Leaders and staff had a shared vision and culture based on listening, learning and trust. However, learning was not always identified through thorough investigations of incidents and complaints were not always managed in line with policy.

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. However, there was a lack of oversight to ensure tasks that had been delegated had been completed.

Managers worked with the local community to deliver the best possible care and were receptive to new ideas. Staff having a good understanding of their patient population and wanted to deliver the best possible care for them to improve health outcomes.

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 practice 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 vision was visible in the practice and staff told us it was discussed in regular team meetings.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. The practice monitored access and planned to keep this under review to ensure they could meet the needs of the growing patient population.

The practice had inclusive clinical leaders who embodied the culture and values of their workforce and organisation. Staff told us all leaders in the practice were approachable, visible and responded to any concerns they raised.

The practice did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk to effectively ensure risks to people were minimised. For example, there was an infection prevention and control policy which stated an annual audit would take place but it had not been completed prior to the inspection so the practice was not aware of infection risks posed to the health of staff and people using the service. Health and safety risks had not been thoroughly identified and mitigated. Blank prescription stationery was not always safely managed. Other areas which required improvement included handling of complaints and significant events to ensure they were managed in line with policy, investigated thoroughly where appropriately, learning identified, and action was taken.

Clinical leaders had the skills, knowledge, experience and credibility to lead and did so with integrity, openness and honesty. However, we found tasks had been delegated to staff and there was no oversight to ensure these tasks were carried out in line with policy, such as an annual IPC audit not taking place, blank prescription stationery not being kept safe, gaps in recruitment processes not being identified or risk assessed.

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

There were policies and processes to support speaking up and these were accessible to all staff online.The practice had a formal freedom to speak up guardian (FTSUG) although not all staff knew what their role was or who it was. The FTSUGs were not external to the provider but were named people not associated with the immediate service. Staff were aware of how to raise concerns.

The practice valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. The practice was conscious of their patient population and wanted the workforce to reflect the community they served. For example, they had identified they wanted to recruit more male colleagues to provide people with more choice about who they saw for care and treatment.

Policies and procedures to promote diversity and equality and staff had completed training in this area.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. The practice had some established governance processes that were appropriate for their service. However, systems of accountability and good governance were not always effective.

Some delegated tasks were not effectively monitored to ensure they had been completed. For example, the annual infection control audit had not taken place, learning from complaints was not always identified and significant events were not fully investigated.

Some new governance processes had recently been introduced and required time to embed into the practice. For example, the practice had reviewed some recruitment files to ensure they either contained all the required information or, had risk assessed information that was missing. However, we identified gaps in files that the practice was not aware of. A new Disclosure and Barring Service (DBS) check process requiring annual staff declarations had been implemented but not fully embedded.

During the inspection, a box of blank prescription stationery was found to be missing from secure storage, while we were reviewing a similar past incident. The sign out sheet was also present and had not been filled in. The box was eventually located as it had been removed by a member of staff, outside of the system in place to keep this stationery safe. The practice said it would log this as a significant event and the importance of auditing prescription stationery was discussed. However, the post-inspection actions shared with us did not include such an audit.

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. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

Staff took patient confidentiality, information and security seriously. However, risks to health and safety were not always identified to keep people using and working at the service safe. For example, windows had been identified as a risk but there was no mention of open windows posing a risk to confidentiality and information security or risks to the safety of people who used the building if unauthorised people entered through the open windows.

The practice 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 practice had well established links with local services in the community that could support people. Partner organisations told us the practice reached out to them to support, educate and encourage people to get their health needs met.

The practice held groups to support their patient population such as a weekly gardening group and a mindful movement group.

They had also been involved in setting up and attending a parent and baby group where they could hold conversations about immunisations in an informal setting. Although funding had ended, the community had been empowered to carry on this group. The practice was hoping to secure further funding to start attending this group again in the near future.

The practice 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. For example, they have moved away from sending flu invite letters to people and now send a message signposting people to book online. This has reduced the amount of phone calls to book flu vaccines appointments.

The practice was proud to be a training practice supporting specialist trainees and medical students from the local university.

The practice had a quality improvement plan in place to help drive improvements in services and had specifically worked on improving access. The practice identified areas for improvement for people with a learning disability and autistic people. The practice had implemented a music group for families of children awaiting an assessment of autism or attention deficit hyperactivity disorder (ADHD).

The practice had frequent attenders and people with complex needs who were seeing multiple clinicians and had to repeat their health story each time they saw someone new. The practice recognised this and implemented a named GP process for this cohort of patients. This helped to streamline appointments and make the practices’ response to people more efficient. For example, a phone call to agree the next steps in someone’s care and treatment for a person by their named GP instead of a clinician unknown to the person requesting a face-to-face appointment and the person having to repeat their health story.

Leaders told us all staff are encouraged to put forward quality improvement projects. Staff gave us examples of where they had been encouraged to put forward and test out new ways of working.