Gray’s Inn Medical Group Vauxhall

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 good. At this assessment, the rating remains the same.

This service scored 68 (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.All staff had contributed to the development of the practice vision and strategy, which was kept under review. The service shared its vision and strategy with the PPG who helped to communicate this with the wider patient population.

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 practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. 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.

Overall, the service fostered a positive culture where people felt they could speak up and their voice would be heard.

We found the service had established Freedom to Speak up arrangements with the Integrated Care Board. However, not all staff were aware of who had been appointed as the Freedom to Speak Up Guardian. Furthermore, the named Freedom to Speak Up Guardian for the practice was a member of the leadership team, and there was a risk that this could discourage staff from raising concerns.

The service had a whistleblowing policy and staff knew how to access this and raise concerns.

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. Adjustments had been made to ensure all staff were valued, for example we found that additional breaks had been offered to staff who needed them. Risk assessments were also carried out when required.

Overall, the service had clear responsibilities, roles, systems of accountability and good governance. However, the service did not always monitor peoples’ care or make sure that medicines and treatments were safe.

The systems in place were mostly used to manage and deliver good quality, sustainable care, treatment and support. All staff 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 appropriate for their service. 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 we spoke to demonstrated that they 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 service had dedicated team that focussed on hospital referrals to ensure that patients received an appointment and to follow up on patients who did not attend.

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 contributed to safe, effective practice and research.

For example, the service allowed patients to book appointments at other practices that were part of the larger group operated by the provider. Patients were able to book appointments at group practices that were closer to where they worked. The service also operated a pharmacy which was able to update patient’s clinical records when appropriate.