Voyager Family Health

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

The practice was last assessed in October 2022 where the well-led key question was rated as requires improvement. At this assessment, we found that the practice had made improvements and the provider’s approach to managing risks was proactive. Our clinical searches found very low numbers of patients who had not had an annual review or monitoring for certain medications. However, we were assured by the practice and saw evidence, of an action plan to encourage non-compliant patients to attend for regular monitoring and reviews and a list of patients who were being contacted to book in their review. We found the provider had clear and effective governance processes, which supported the safe delivery of care. There was an experienced leadership team who had clear oversight within the practice service. There was compassionate, inclusive, and effective leadership. Staff were very positive about the leadership and told us they felt listened to and supported.

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.

Leaders were able to demonstrate that they had the capacity and skills to deliver high quality sustainable care and that they understood the challenges to quality and sustainability. Improvements that had been implemented were embedding. Staff reported there was an open and honest culture within the practice, were proud to work for the service and held a shared objective to deliver high quality patient care. There was an emphasis on the safety and well-being of staff.

Systems and processes existed to ensure a positive, collaborative and compassionate culture continued. Staff and leaders, we spoke with explained how equality and diversity were a priority for the practice. Leaders prioritised transparency and learning to ensure safe, high-quality compassionate care was delivered. The provider had a Business Development Plan. The plan set out details of the strategic goals for the forthcoming three-year period and was tailored to meet the requirements of the practice population. This included training and workforce development, communication, and strategy development which involved staff in the future of Voyager for maximum engagement and development.

Staff told us there was compassionate, inclusive and effective leadership at all levels. They were knowledgeable within their role and prioritised the quality of the service they delivered with appropriate support to all staff. Staff we spoke with told us leaders were very supportive of staff and available for any questions or support when needed. Staff felt leaders were open, honest and always demonstrated integrity. Staff told us leaders listened to their feedback and shared some examples where changes had been made. Staff told us they received regular appraisals and were given various opportunities to discuss development and training. They told us management had an ‘open door’ policy and they could approach leaders at any time if they required support. We saw evidence of a strong emphasis on staff development and well-being.

There was an experienced leadership team who had clear oversight within the practice. Leaders were knowledgeable about issues and priorities for the quality of the service and had the experience to ensure that risks were well managed. Staff felt they could raise concerns and felt listened to by the management. Staff said they were kept informed of any changes. Staff attended meetings and could add to agenda items. Minutes were shared with all staff and those who were unable to attend such meetings. Practice policies had been reviewed and kept up to date. There were processes to manage performance, and staff were aware of their roles and responsibilities.

All staff we spoke with had a clear understanding about the Freedom to Speak Up processes within the practice. Staff felt there was an open and transparent culture within the practice that encouraged people to raise concerns and staff did not fear any negative repercussions if they spoke up. Staff were confident that if they raised a concern they would be listened to.

The provider had a clear whistleblowing policy which encouraged staff to speak up if they are genuinely troubled. The policy stated that the provider was committed to listen to staff, learn lessons and improve patient care. The provider had a Freedom to Speak Up guardian and the policy provided staff with details of the key organisations and contacts relevant to the speaking up agenda both nationally and locally. We saw evidence during our visit of how the practice promoted a culture of openness and supported staff to speaking up and share concerns at the earliest opportunity.

Staff we spoke with told us they felt there was a fair and inclusive workplace within the service, and none had any concerns about inequalities. All staff and leaders spoken with confirmed there was zero tolerance for any forms of bullying, harassment or discrimination within the practice. They told us there was an inclusive and fair culture and they could approach leaders at any time if they required support.

Policies and processes reviewed confirmed the practices’ commitment to equal opportunities, equality, diversity and inclusion. The practice was a registered Tier 2 sponsor (A Tier 2 sponsor is a UK employer that has been granted a license to hire skilled workers from outside the UK) and encouraged applicants from overseas. Staff could request flexible working and where possible staff could work remotely. Some staff members were encouraged to work to a time management method based on stretches of focused work broken by short breaks to help with mental fatigue. The practice had a private space to allow for religious practice. There was a diversity champion within the practice.

We spoke with a range of staff with differing levels of experience, and they all understood their roles and responsibilities and how to carry out their duties to ensure the safety of both patients and the workforce. Staff told us there was opportunity to talk with leaders on an informal basis as well as through regular supervision and appraisals. This ensured staff were confident and competent to carry out their roles. Staff we spoke with confirmed they could access policies and procedures from a centralised system. Staff told us they were encouraged to speak up and where needed discussed openly concerns and were involved in finding solutions. Staff were aware of the process to raise significant events and encouraged to do so. Leaders explained various systems and processes which provided an oversight of risk and performance and how these were monitored to assure them the quality of the service was maintained and improved.

Leaders were aware of the work and any improvements required to maintain and improve the level of care and treatment to patients. Through our searches of clinical records of patients, we found a low number of patients with long term conditions or patients prescribed high risk medicines who had not received regular monitoring or annual reviews. The leaders were responsive to our findings and sent us an action plan. This included contacting those overdue a review and encouraging non-compliant patients to attend. We saw evidence of practice staff working as a team to improve processes to ensure they were working as intended. There was an understanding of what the challenges were, and leaders had put actions in place to address them. Structures, processes, and systems of accountability were clearly set out, understood and effective. We saw evidence of a wider shared learning and the involvement of staff at all levels to ensure continuous improvement. There were comprehensive assurance systems which were regularly reviewed and improved. This included risk assessments and learning from safety alerts and significant events. Clinical and internal audit processes had a positive impact on quality governance, with clear evidence of actions taken to resolve concerns.

We did not receive any feedback from people who used the service relating to partnerships and communities.

Staff and leaders, we spoke with told us they understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement. The management and leadership team met regularly to discuss challenges within the practice and ways in which they can improve the quality of care to better serve the practice population and improve relationships with external agencies.

We received no concerns from partner organisations regarding how the practice worked with partners and communities.

Leaders and staff attended monthly meetings with external stakeholders. This included attending Integrated Care Board meetings and Practice Managers’ meetings. Leaders also held regular meetings with the Multidisciplinary team (MDT), Palliative care team, Primary Care Network and local initiatives such as Asylum movement. These meetings helped to share learning with each other and identify new or innovative ideas that can lead to better outcomes for people.

Staff informed CQC that they were happy working at this practice and were supported to be effective in their roles. We saw examples where staff were encouraged and supported to take on new roles and responsibilities in the practice. The leaders understood the vision, the current performance and areas that needed to be improved and set up action plans to ensure the improvement occurred in time specific manner. All staff we spoke with confirmed that the practice was focused on learning and continuous improvement. Staff felt encouraged to raise ideas for improvements to processes and reported they always received feedback and an explanation if something was not possible.

We found evidence that the practice had established processes to gather feedback from staff and patients. When changes were made or new systems were introduced, their effectiveness was evaluated and if necessary further changes were made. For example, the practice had received feedback via the NHS App, that some patients had sent messages asking to synchronise their medication, but this had not been actioned. The practice adopted a new process to ensure requests were passed to the relevant team (for example the pharmacy team) to action. The new process had improved the quality of the repeat prescription service for patients. Staff were supported to prioritise time to develop their skills around improvement and innovation. Staff were encouraged to contribute to improvement initiatives. Protected time was available to staff to complete training or projects, the practice leaders were enthusiastic regarding the development of their workforce.