Cleckheaton Group Practice Also known as St John's House

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. We found leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback. Staff understood their roles and responsibilities. Leaders worked with the local community to deliver the best possible care. At our last inspection, 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 practice told us their vision was to provide compassionate and caring services to the community they served. We saw that the practice’s vision was underpinned by their core values of openness, fairness, respect and accountability. Although staff were aware of the vision and values, they had not been developed in collaboration with them. There was a business plan in place which highlighted challenges, strategies for risk mitigation, and future plans for the practice. One of the GP partners was training to be a GP trainer.

There was a stable clinical leadership team in place who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge and experience to lead effectively. Staff told us that managers were visible and approachable and that they felt supported by them. At our last inspection, the leadership had talked about challenges with staff retention and recruitment of practice nurses and reception staff. At this assessment we saw new clinical and non-clinical staff had commenced at the practice. Staff told us the practice worked well as a team and although some acknowledged that at times the pressures of primary care could be stressful, they felt they all pulled together, and they could seek help and guidance from leaders and colleagues. Staff told us they enjoyed a recent wellness walk organised by the practice.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. There were policies in place for Freedom to Speak Up and Duty of Candour and staff had undertaken training. There was a nominated Freedom to Speak Up Guardian. Concerns could be raised openly and confidentially or anonymously to support any staff members raising concerns. We saw an example where the duty of candour had been applied following an incident.

Policies and procedures to promote diversity and equality were in place and staff had undertaken equality and diversity training. Overall, staff reported a positive and fair culture at the practice, with adequate support and regard for staff wellbeing. Some staff gave examples of support they had been given by the practice, both personal and professional. There were systems and processes in place to support the safety and well-being of staff. This included policies and training on lone working and bullying and harassment. Staff had undertaken conflict resolution and customer care training to support them in their roles.

At our previous inspection, we found gaps in governance systems. In particular, processes to ensure safe recruitment, premises, infection prevention and control and some medicines management. At this assessment, we found the provider had made improvements and had established clear responsibilities, roles, systems of accountability and good governance. There was an organisational structure in place and nominated clinical and non-clinical leads for key areas whom staff could contact for advice and support. For example, safeguarding, incidents, complaints and infection control. Staff we spoke with were clear about their role, responsibilities, and how they interacted with other staff. They told us they had access to policies and procedures to support them within their role and attended regular meetings where discussions about the practice, such as complaints and significant events, were discussed. There were systems in place to ensure staff had an annual appraisal and ongoing performance review. There were processes in place to ensure data management and security. The practice was registered as a data controller with the Information Commissioner’s Office (ICO). Staff took patient confidentiality and information security seriously. Staff we spoke with told us they followed the practice’s confidentiality policy when discussing patients’ treatments. This was to ensure that confidential information was kept private, for example, patient information was never on view and personal smart cards were removed when not in use. We saw that all staff had undertaken information governance, data security awareness, cyber security awareness and confidentiality training. There was a business continuity plan in place, which we saw had recently been updated when new staff commenced at the practice.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The practice engaged with the neighbouring practices in local current and future initiatives which included the primary care network (PCN) (an approach to strengthening and redesigning primary care to focus on local population needs). We saw there were regular PCN meetings. In addition, the practice was collaborating with a separate PCN to deliver the COVID vaccine to their patients. Leaders told us they used a range of methods to gather patient feedback. For example, from the National GP Patient Survey, Friends and Family Test (FFT), complaints and compliments. Staff told us they could provide feedback through meetings, a suggestion box and annual appraisal. The practice had an active Patient Participation Group (PPG). We spoke with a member of the PPG who told us they met quarterly. They said the practice was receptive and responsive to feedback. The PPG was currently looking at ways to communicate services provided by the practice by creating an information presentation to be played through the information screen in the waiting room.

The practice focused on continuous learning, innovation and improvement. The practice had a schedule of clinical audits and quality improvement initiatives. A range of data was collected and reviewed to improve service delivery and drive outcomes for the patient population. For example, we saw reviews of incidents, patient feedback and audits. Staff told us they were supported to undertake further training and acquire new skills.