Hazelwood 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

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders had a detailed vision and values for the service. Some staff told us they felt engaged by leaders at the service. They told us they were listened to and had contributed to the development of the service. Staff were supported and encouraged to maintain up-to-date knowledge and skills through ongoing professional development, ensuring they could effectively contribute to the quality and safety of the service.

Not all leaders consistently demonstrated the culture and values of the workforce and the organisation. Some staff told us that leaders were not always approachable and did not respond in a timely manner to concerns raised. However, other staff told us that the leadership team were supportive and open to feedback. During our on-site visit, leaders acknowledged the feedback and expressed a commitment to improving communication, visibility, and inclusivity within the team. There was evidence that leaders were beginning to take positive steps towards fostering a more collaborative and transparent culture such as frequent staff surveys and had identified actions from this.

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 felt confident they would be dealt with appropriately.

The service valued diversity in their workforce and promoted 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. Staff had received quality, diversity and inclusion training.

While leaders and managers were supportive and staff understood their roles, governance arrangements did not consistently provide assurance. Regular meetings, appraisals, and access to policies were in place, and staff demonstrated awareness of confidentiality and information security. However, risk management systems required improvement, including monitoring and prescribing of high-risk medicines, repeat auditing of patient safety alerts, and the depth of quality outcome audits with reflective learning. The management of emergency equipment and medicines needed strengthening, and further action was required to achieve full IPC compliance. Governance policies existed but were not fully embedded to ensure robust oversight. The provider was responsive to feedback and committed to implementing improvements following the inspection.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The PPG were positive about the provider and the work they were doing to improve access for their patient population.

The service worked within a multi-disciplinary team to provide the right support for everyone. The staff actively participated in regular meetings where people’s care and treatment needs were discussed to improve their outcomes. On inspection we found a lack of effective quality outcome audits, including reflections on procedures and how outcomes might be improved, we found governance systems needed to be strengthened which evidenced a lack of focus and continuous learning and improvement within the service.