ELM Alliance @ Park Surgery

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
This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.
 

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 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. Staff contributed to the development of the service vision and strategy, which was kept under review.

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. They did so with integrity, openness and honesty.
Staff told us leaders in the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. We saw the leadership team worked with other services in the primary care network and were engaged in the development of primary care services within the local area. The service took part in regional initiatives which promoted better health and wellbeing for staff at work and had received regional recognition for this work.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.
The service had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns. A whistle blowing policy was in place and staff knew where to locate this.

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.
Policies and procedures to promote diversity and equality were in place. We saw adjustments had been made to ensure all staff were valued. For example, we saw adjustments to support staff to practice their faith through the provision of quiet spaces for prayer within the service. When we inspected there was a draft code of conduct that was being updated to incorporate principles that underpin aspects of operations, governance, and service delivery.
 

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. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.
Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. We saw evidence of regular staff capability reviews to ensure staff were in appropriate roles. 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 service meetings with staff, during which they discussed clinical concerns and emerging risks. Leaders were proactive in reviewing their own processes and when we assessed this service, they had completed a mock assessment of their service and developed an action plan.

The provider worked with core hours GP practices within their primary care network to offer extended access services. 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. There were clear processes and information sharing arrangements to ensure effective collaboration.

The service focused on continuous 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. They actively contribute to safe, effective practice and research. For example, they coordinated and delivered Practice Learning Time (PLT) sessions across the federation. These sessions were designed to support continuous professional development and service improvement within the federation.