Brierley Park Medical Group

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

Well-led – this means 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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 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. Staff were aware of the vision however, they had not been involved in developing it. The practice had merged with another practice 17 months ago and had worked closely with partner agencies to address the challenges this had presented. Staff were positive about the culture within the practice and described it as open and transparent.

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 which was demonstrated through the take-over of the branch practice 17 months ago. The leaders were aware there were ongoing issues that still needed to be addressed within the branch practice and had plans in place to do this. Staff were feeling more positive about the future now the take-over has been completed. Staff told us leaders were visible and approachable and mostly responded to any concerns raised. The leadership team worked well with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. There were systems in place to support staff to whistle blow or to speak with a Freedom to Speak Up Guardian if they had any concerns. Staff were aware of how to whistle blow and who the Freedom to Speak Up Guardian was and what their role was in supporting staff. Staff felt that they could speak up and most felt that their voice would be heard and acted upon.

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 had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. Leaders and managers supported staff, and staff were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. They mostly acted on the best information about risk, performance and outcomes. However, leaders did not have access to a fire risk assessment for the main practice and there was no action plan available to demonstrate what actions were taken to address the risks identified in the fire risk assessment for the branch practice. There was a suite of policies to support good governance however, policies relating safeguarding, maintenance of the cold chain, recruitment of staff and prescribing of medicines did not fully reflect the needs of their practice population and national guidance. Following our assessment the provider forwarded to us appropriately updated policies for recruitment, safeguarding and cold chain maintenance.

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 provider worked with other practices within their primary care network (PCN) to offer extended access appointments. The practice had a very active Patient Participation Group (PPG). A representative from the PPG told us that their views were acted on and they worked closely with the practice to improve services. For example, the purchasing of raised chairs for the reception area and collaborative working to support the smooth running of flu clinics. There were processes in place to work in partnership with key organisations and agencies to support the provision of care and joined up working. For example, district nursing teams, community matrons and Health Visitors. Feedback from representatives of 3 care homes where the service provided care and treatment was overwhelming positive about the GPs that provided regular ward rounds in the homes to review people on a regular basis.

The service focused on continuous learning and improvement across the organisation and local system. They actively contributed to safe, effective practice and research. For example, the practice had joined a pilot to improve the uptake of cervical screening in the transgender population. Leaders had met with previous health ministers to discuss how to improve access to care for their deprived population and participated in research to improve access to mental health services within deprived areas. They used learning from significant events and complaints to continually improve the service they provided. The practice had analysed the results of the latest National GP Survey and made positive changes to address issues identified. For example, an upgrade of their telephone system to improve telephone access to the practice and added links to their website to support online consultations.