Heswall and Pensby 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 75 (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 clear vision and values which guided the development of the organisation and supported improvement activity. Leadership responsibilities were shared across the partnership, supporting accountability and collective ownership of strategic and operational priorities.

Staff were actively involved in developing the vision and values of the organisation. Staff we spoke with described opportunities to contribute ideas and feedback and understood the direction of the service and the reasons behind ongoing improvement activity.

Leaders promoted a positive and inclusive culture. Staff described leaders as approachable and supportive and felt able to discuss concerns, feedback and ideas for improvement. Communication and engagement arrangements had been strengthened following a period of organisational change.

The provider supported staff development through training, supervision and professional development opportunities. Workforce wellbeing, development and organisational culture were regularly reviewed as part of wider service improvement activity.

Staff feedback and survey results demonstrated a positive culture in which staff felt supported, listened to and involved in the development of the service.

Leaders had the skills, knowledge and capacity to lead the service. Leadership responsibilities were clearly defined and shared across the organisation, helping ensure oversight of key areas such as governance, patient safety, workforce development and service delivery.

Leaders demonstrated insight into areas requiring improvement and responded positively to organisational challenges. They had strengthened governance arrangements, improved oversight processes and implemented improvement activity following a period of organisational change.

Staff described leaders as visible, approachable and supportive. Staff we spoke with felt able to raise ideas, discuss concerns and access support when required. Leaders were responsive to feedback and had implemented changes to address issues raised by staff.

The provider involved staff in the development of the service and used feedback from staff surveys and engagement activities to inform improvement work. Leadership decisions reflected feedback from staff and supported a more inclusive working environment.

Leaders had also taken steps to support the long-term sustainability of the service through workforce planning, succession planning and the development of future leaders.

The service promoted a culture where staff felt able to raise concerns about patient safety, quality of care and organisational issues. Staff we spoke with understood how to raise concerns and described leaders as approachable and willing to listen.

The provider had a freedom to speak up policy in place and staff were aware of the different routes available for escalating concerns. Staff were able to identify freedom to speak up champions and understood how to access additional support if required.

Leaders encouraged openness, learning and improvement. Concerns raised by staff were reviewed and used to inform service improvements, training and governance activity. Staff described feeling comfortable sharing ideas and feedback about the development of the service.

Staff feedback was actively sought and used to inform changes to communication, wellbeing and workforce support arrangements. Staff we spoke with reported confidence in raising concerns and felt these would be listened to and acted upon where appropriate.

The provider promoted an inclusive working environment where staff felt respected, valued and supported.

Leaders considered individual needs when providing support, supervision and development opportunities. Staff described a flexible approach which recognised that people develop confidence, skills and experience at different rates.

The provider considered requests for flexible working and workplace adjustments on an individual basis. Staff told us they felt supported when adjustments were required and that individual circumstances were considered when decisions were made.

Staff were encouraged to contribute ideas and feedback regarding the development of the service. Staff we spoke with described an inclusive culture in which people felt supported and able to contribute to improvement activity.

The service had clear responsibilities, roles, systems of accountability and governance processes. These were used to manage and deliver good quality, sustainable care, treatment and support. Leaders used information about quality, performance and organisational risks to support decision-making and improvement.

Staff we spoke with were clear about their individual roles and responsibilities. Leaders maintained oversight of performance, patient safety, workforce matters and organisational risks through established governance arrangements. The provider had implemented a governance improvement programme and had strengthened oversight arrangements following organisational change.

However, governance processes were not always fully effective in ensuring all risks and assurance processes were consistently identified and monitored. We identified concerns relating to environmental risk assessment processes, staff immunisation monitoring and some infection prevention and control assurance arrangements. Leaders had already recognised the need to strengthen aspects of governance oversight and assurance and had implemented a governance improvement programme. Following the assessment, leaders took prompt action to address the concerns identified.

Staff could access policies, procedures and guidance relevant to their roles. Leaders reviewed patient feedback, organisational performance and improvement activity and used this information to support the ongoing development of the service.

The service worked collaboratively with a range of organisations to support patient care and service development. Leaders described improved relationships with PCN partners and a renewed focus on collaborative working following a period of organisational change.

The provider maintained effective working relationships with community pharmacies, community services, specialist teams and other partner organisations. These arrangements supported continuity of care and coordinated support for people with complex needs.

Feedback from care homes indicated that the service worked positively with residents, care home staff and other professionals. Care homes described good communication, collaborative working and ongoing support from clinicians.

The provider maintained an active PPG and provided opportunities for people to contribute to discussions about patient experience and service development. Members described improved relationships with the service and recognised positive changes in organisational culture.

The provider also maintained links with educational organisations and research networks, helping to support workforce development, innovation and service improvement.

The service promoted a culture of learning, reflection and continuous improvement. Leaders used learning from incidents, significant events, complaints, audits and patient feedback to identify opportunities for improvement and support service development.

Staff were encouraged to reflect on their practice and learning formed part of supervision, appraisal and professional development activities. Learning needs identified through supervision and audit activity were used to support training and workforce development.

The provider used quality improvement activity to review the effectiveness of services and improve patient care. Audit findings were used to strengthen systems, monitoring arrangements and clinical processes. Leaders reviewed the impact of changes made and used re-audit activity to assess whether improvements had been effective.

The service used feedback from staff and patients to inform improvement activity. Leaders demonstrated a willingness to review existing processes, seek external assurance where required and implement changes in response to learning.