Victoria 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

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and provided examples of where this had been accepted and introduced into practice. Staff were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

Since the last inspection, the practice had made improvements and is no longer in breach of regulations for safe care and treatment, and good governance.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

The service was previously found to be in breach of legal regulation in relation good governance. We found, leaders who lacked oversight of some processes and therefore failed to identify risks when those processes did not operate as intended. The practice also did not always act on appropriate and accurate information.

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.

The practice had gone through a restructure including changes to their management team, which had been unsettling for staff. The provider had introduced a staff committee to encourage staff to be visibly involved in the direction and culture of the service capturing thoughts, ideas and suggestions. This was welcomed by staff as positive and inclusive and the committee met monthly.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders 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 the partners in the practice were approachable and discussed and responded to any concerns raised. We saw the leadership team worked 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. Staff told us they were encouraged and supported to speak up and some staff believed their voice would be heard and acted on if appropriate.

The practice had established Freedom to Speak up arrangements internally and with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The service valued diversity in their workforce. They work 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. Staff spoke positively about their colleagues and working environment. We saw staff had had adjustments made to support them at work. The provider conducted anonymised annual staff well-being and satisfaction surveys to encourage staff to share their experiences and used the information to inform changes. For example, revising the staff working arrangements.

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 act on the best information about risk, performance and outcomes, and share 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. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were clear, comprehensive and appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed collective performance, clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff, reviewed and resolved them. 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 share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services.

The practice regularly monitored their clinical performance. Weekly meetings were held which included discussion and analysis of the care of people at higher risk of hospital admission.

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.

Staff told us learning was promoted and considered an individual and collective priority.

The practice had a quality improvement plan in place to help drive improvements in services such as strengthening their medicine management practices and improving patient access to services. Staff were encouraged and supported to put forward and test out new ways of working. Staff provided examples of suggestions that they had put forward to the management team. These had been discussed, accepted and implemented and had resulted in improvements for staff and been beneficial for patient outcomes.