Holyhead Primary Healthcare Centre

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 carried out an announced assessment of all 7 quality statements under the well-led key question. We found there was an inclusive and positive culture of continuous learning and improvement shared by all staff. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred, sustainable and reduced inequalities. Leaders understood their local population and endeavoured to provide inclusive, flexible and accessible services within the practice and in community settings. Overall, leaders had implemented effective governance and management systems. Where we identified gaps, we raised this with leaders during the assessment, who took immediate action to review systems and provide assurances that reduced the level of risk. Information about risks, performance and outcomes was used effectively to improve care.

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.

Staff told us there was an open, honest and transparent culture at the practice; they felt able to raise concerns without fear of retribution. Leaders were honest when things went wrong, did not seek to allocate blame and provided apologies when necessary. There was an emphasis on the safety and well-being of staff. Staff reported that leaders were visible and approachable. Leaders had developed a shared vision and strategy and most staff knew and supported it. All staff understood how their role helped in achieving the strategic goals of the practice. Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service and was focused on learning and improvement. Staff at all levels prioritised safe, high-quality, compassionate care. They demonstrated a strong desire to help and support their patients, and to grow and develop as clinicians.

The practice had a clear vision and credible strategy to provide high quality sustainable care. The mission statement was ‘To provide our patients with personal health care of high quality and to seek continuous improvement on the health status of our population’. The practice had a culture which supported this vision. Leaders used all the available data to monitor performance and outcome, plan for the future and drive forward improvements. Staff reflected the practice values when talking about patient care. There were a range of appropriate policies and procedures to facilitate open and honest communication, to support equal opportunities for both staff and patients, to prevent discrimination and to promote human rights. Leaders had a business plan which set out a clear direction for the future of the practice.

The leadership team showed integrity, were experienced, worked well together and had developed an open-door culture that was honest and transparent. The leadership team had a clear plan to improve the services and outcomes for patients. Staff shared the values modelled by the leadership team and spoke warmly of an inclusive culture which motivated them to strive for excellence.

We saw evidence that the leadership team were appropriately skilled and experienced. The practice had policies in place which allowed the leaders to identify clinical priorities and mould services to meet the needs of the population. There was a system to incorporate patient feedback into decision making processes. Fair and non-discriminatory recruitment practices allowed the practice to build an appropriately skilled and motivated workforce. We saw that where recruitment of the right staff was not possible, the use of long-term locums provided a stable workforce and encouraged locum staff to be integrated within the permanent team.

Safety was a priority and leaders had an honest approach to dealing with instances where things went wrong. All staff felt confident they could raise concerns within the practice and they would be listened to. Staff told us when they did raise concerns or incidents, leaders addressed the issues and staff were told about actions being taken to prevent the same happening again. Staff we spoke to knew how to access the Freedom to Speak Up Policy (FTSU) and who the FTSU guardian was.

The practice had a FTSU policy and guardian. All staff had been given training in how to speak up. The practice also had appropriate duty of candour and bullying and harassment policies in place. There was a structured process to follow when things went wrong, from incident reporting to investigation and feedback. Leaders analysed trends in complaints and learning events annually to learn from themes or trends and take action to improve.

Staff told us they felt supported by the practice leaders and their peers. Staff spoke about opportunities for learning and how the practice supported them in their continuing professional development. Staff felt empowered and were confident that their concerns and ideas resulted in positive change. Staff worked well together as a team and included long term locums and staff employed by the PCN within their supportive and friendly environment. We saw staff had regular appraisals that included opportunities to discuss their performance, future goals and development needs. Leaders told us that having a multilingual staff that reflected the community they serve improved communication and understanding for patients. Staff told us it was a positive workplace, where they felt listened to and supported by their leaders. Several staff described it as like a family or their home from home.

There were systems and processes to ensure there were clear responsibilities, roles and accountability structures to support the workforce. Staff were supported through supervision, appraisal and regular staff meetings. The practice leaders celebrated successes and achievement by nominating a staff champion every month, which staff found motivating. Staff had access to occupational health support and an employee assistance programme that including access to counselling services. Staff and leaders had undertaken equality and diversity training. A sample of staff files we examined at random showed that practice had fair and equitable recruitment procedures.

Leaders were able to discuss clear governance structures and lines of accountability. Staff had clear roles, scope and responsibilities including non-patient facing roles for example, IPC lead. Staff knew who led on specific areas such as the Caldicott and Freedom to Speak Up Guardians and the safeguarding lead. Leads took responsibility for identifying and mitigating risks. They recorded relevant data and acted when required which was then shared with the rest of the team. All staff were aware of and could access a range of governance policies and had appropriate training for example in confidentiality and information governance. Staff also clearly understood the roles and responsibilities of their colleagues and worked well together as an integrated team.

We found there to be a range of suitable, comprehensive and up-to-date policies and risk assessments to support staff in providing safe and effective care. These included plans to ensure business continuity in case of major incidents such as IT failure, to ensure staff and patient safety in the event of fire and to provide treatment in the case of a medical emergency such as a cardiac arrest. We saw a range of regular audits were conducted to monitor performance and risk in order to maintain the safety of staff, patients, equipment and the premises. For the majority of these audits action plans were in place recording any remedial action taken. The practice used digital services securely and effectively and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management. The practice was registered with the Information Commissioner’s Office. Staff used data to monitor and improve performance. We found the workflow of managing information, such as hospital letters and medical record summarising were up to date.

The practice actively engaged and sought feedback from patients through in-house surveys, the national Friends and Family Test and their regular “afternoon teas.” There were 3 different language-based Patient Participation Groups (PPGs) and the member we spoke with was positive in their reflections of the practice and how they were engaged as a group. PPG meetings also included a health education component which encouraged attendance.

We found staff and leaders were open, transparent, and engaged with their PCN and ICB regularly. They showed us communication with their PCN / ICB where they had been asked to present information on their work about safeguarding and learning disabilities with the rest of the PCN / ICB, sharing good practice. Staff spoke about how long-term locum staff and PCN employed staff such as the social prescribers were all included as part of the team. The social prescribers engaged with local communities such as the mosque and the library to provide health checks in their premises. Staff had regular meetings with community staff such as Health Visitors to discuss patients on their safeguarding register.

We saw feedback from 2 other healthcare professionals who work with the provider including from the local pharmacy who described the practice as very approachable and their working relationship as “exceptional”.

We found the practice to be an active and engaged member of their PCN open to sharing good practice and embracing new ideas that could improve outcomes for their patients. There were effective systems in place to allow staff to communicate and collaborate with external clinical partners. Leaders had employed external partners to undertake specific work such as a capacity / demand analysis to help them improve access. The practice had numerous accreditations and worked with external stakeholders such as Shelter and Iris to provide specific support services to their population.

Leaders explained that they logged information about complaints and learning events and analysed this information annually. This allowed them to identify trends and learn lessons when needed. Staff had opportunities to learn from audits, incidents and complaints and to discuss the quality and delivery of their services at regular clinical governance meetings. Staff described how they were supported to develop their role and specific interests for example one HCA was beginning a nursing apprenticeship. All HCAs had defined areas of interest and took pride in excelling in them, for example the smoking cessation clinics. The social prescribers were providing a wide range of additional opportunities for patients to engage with health education and self-management. Leaders aimed to become a training practice for GP trainees.

Staff and leaders ensured that people using the service, their families and carers had opportunities to provide feedback on care received, and improvements. Leaders worked with the Primary care network (PCN) to improve access and outcomes across the local patient population and were open to new ideas and ways of working. Leaders were aware of the current challenges to their practice for example access and had taken action to improve their understanding of the scope of the problem (which is a national one). Due to the nature of their local population the practice had focused on certain areas of improvement such as attendance for cancer screening programmes, TB screening and diabetes management and we saw evidence that they were making a clear difference for patients. There were processes in place that allowed staff to identify areas for development or special interest and they were encouraged to grow and develop as clinicians.