Great Barr Medical 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 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 Requires Improvement. At this assessment, the rating has remained the same.

At our last assessment, the service was in breach of legal regulation in relation to:

• There were no systems in place to ensure systems and processes were effective to identify and assess risks to the health, safety and/or welfare of people who use the service.
• The provider was unable to demonstrate a culture that encouraged candour, openness and honesty at all levels.
• We found no evidence that there were policies and procedures in place to support a culture of openness and transparency.

At this assessment, the service was in breach of legal regulation in relation to:

• Governance processes were ineffective in assessing, monitoring and mitigating the risks relating to the health, safety and welfare of people.

At the last assessment we found the practice did not have a fully embedded governance system, there was a lack of leadership and oversight, there was no evidence that there were effective arrangements for identifying, managing and mitigating risks and there was no evidence of systems and processes for learning, continuous improvement and innovation.

At this assessment, we found that the provider had taken action to address some areas of governance, management and accountability, however we found the systems to manage performance to ensure staff had the skills and knowledge required further strengthening so people had safe care and treatment.

We found that the leadership team had been strengthened with 1 new GP partner, 2 non-clinical partners and a new practice manager. The practice had designated roles for areas of accountability. There were succession plans in place, supported by a business plan and the practice had made significant improvements to ensure quality outcomes were fully sustained.

Leaders and staff shared a clear vision and culture in listening, learning, and mutual trust. Staff told us the leadership team were supportive, actively fostering staff development. Staff reported feeling empowered to provide feedback and described a workplace culture that promoted equality and was free from bullying or harassment. Roles and responsibilities were well understood across the team. A culture of continuous improvement was evident, with staff supported through time and resources to explore and implement new ideas.

This service scored 61 (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, strategy 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.

At the last assessment we found the practice culture did not always effectively support high quality sustainable care. Learning from incidents and complaints was not shared with the team to improve the quality of the services provided and mitigate risk.

At this assessment we found significant improvements in the culture with staff reporting a unified approach now in place to sustain the improvements that had been implemented with continuous focus on quality and safety. Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care. Team members highlighted effective communication and stated that they felt included in decision making processes relating to the service.

The practice website set out its vision and values, which included working in partnership with community organisations, responding effectively to patients’ medical needs and using technology to enhance efficiency and effectiveness. Staff we spoke with were aware of the vision and values.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

There was an open culture and clear learning within the practice. Regular meetings were held with staff and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

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, but clinical oversight and supervision needed further improvement.

At the last assessment we found a lack of clinical oversight and supervision to ensure staff were carrying out their roles effectively and the leadership team were aware of the skills and knowledge of the staff they had employed. At this assessment we found some improvements had been made, with a review of staff in clinical roles, however further strengthening of this process was required as we still found staff carrying out clinical reviews without the appropriate knowledge, experience or awareness of clinical guidelines. We were unable to gain assurances that the leaders had an effective process in place to monitor all staff carrying out clinical duties.

Staff told us leaders in the practice was approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN 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 regular meetings held with staff and there was a freedom to speak up guardian in place. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve. All staff had undertaken equality and diversity training.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were well supported and felt able to ask for advice. The leadership team had implemented a stress risk assessment to identify any concerns staff may have with their workload and to provide additional support if required. Staff told us they were encouraged to develop within their roles and training opportunities were available. The leadership team had recently implemented a monthly shining star award to promote staff’s contribution to practice achievements. This provided opportunities for staff to feedback on their colleagues innovative approach to the care and support of both patients and staff.

The service had clear responsibilities and systems of accountability, however governance processes needed strengthening to ensure risks were identified and actioned.

At the last assessment, we found the practice was unable to demonstrate that there was clear oversight of governance arrangements to ensure risks to patients were considered, managed and mitigated appropriately. At this assessment we found some improvements had been made, but required further strengthening to ensure all risks were mitigated. For example, medicines management and an effective system for maintaining the safeguarding registers. We continued to find that clinical supervision and oversight was inadequate with staff working outside of their competencies.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders told us they worked with stakeholders and the local community. The practice was part of a Primary Care Network (PCN) which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

Since the last assessment, regular meetings were now in place and learning was shared from incidents, and complaints improvement plans were regularly discussed. In addition, the practice held regular clinical meetings to collaborate effectively and make improvements in patients care and treatment.

A patient participation group (PPG) was in place and meetings were held regularly, on average every 2 months. There were 7 active members. The practice had engaged with the PPG on areas of improvement such as patient survey feedback, access and planned improvements. Feedback from the PPG highlighted the changes that had happened in the past 12 months at the practice with telephone access having improved following the implementation of e-Consult.

The leadership team had been involved in a number of initiatives to improve patient care and provide support as required. For example, the practice had held a Macmillan coffee morning to raise money for the cancer trust and had another one planned for later in the year. A breast cancer awareness afternoon tea was also planned for people to provide information and advice.

The leadership team were aware there had been increases in demand and they were working with the PCN and stakeholders to ensure that resources were planned with continued collaboration and partnership working to meet the needs of the service.

The service focused on learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

At the last assessment we found no evidence to demonstrate learning from incidents and complaints was shared with staff to mitigate future risks. At this assessment, we found significant improvements in the sharing of learning with the practice team, with regular meetings now in place.

The provider had made improvements, however we continued to identify concerns in the management of staff in clinical roles with no clear oversight of their skills and knowledge to be able to carry out reviews of patients effectively. We identified continued gaps in the knowledge of some staff in relation to national clinical guidelines.

Feedback from staff and people who used the services of the practice, highlighted the improvements that had been implemented over the past 12 months. This included the implementation of e-Consult, increased staffing to answer telephones, a new management team and participation in a range of initiatives to improve quality outcomes for patients. For example, the practice had recently held a diabetes workshop to provide information and support to patients.

The practice had a quality improvement plan in place to help drive service delivery. This included regular monitoring of the appointment system, attendance of one of the leadership team at a cancer champion training event and also the completion of a mental health first aider course.

The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.