Ravenscroft Medical Centre

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• 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.

We rated this key question as good. Overall, staff we spoke to told us they felt supported, and the service was actively engaged with initiatives to address health inequalities within the local community. Patient feedback was largely positive, however leaders and managers did not always have full oversight of systems and processes to promote effective and safe service provision.

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.

Score: 3

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 had contributed to the development of the practice vision and strategy. Staff told us it was a positive workplace, where they felt well supported by their leaders. However, some gaps were identified in staff training and systems in place for supervision were not always clear.

Score: 3

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, although gaps were identified in governance and oversight of clinical staff with regards to recall and prescribing processes. The provider had not carried out any staff surveys at the time of assessment.

Staff told us leaders in the practice was 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.

Score: 3

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they understood how to raise concerns and were confident that the leaders would act on them.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff had completed whistleblowing training and there was a whistleblowing policy in place.

Score: 3

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. The provider offered flexible working options to accommodate staff needs. Staff and leaders were representative of the population of people using the service.

Score: 2

We found the provider did not always have clear and effective governance processes, which supported the safe delivery of care. The provider did not always have clear responsibilities and systems of accountability.They did not always act on the best information about risk, performance and outcomes. Data reviewed as part of our assessment indicated that not all prescribed medicines were being monitored in line with the services own policies and procedures or national guidelines.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Appraisals were up to date. Staff knew where to access all required policies and procedures. We saw evidence of meetings taking place in the form of minutes, however some staff reported that learning was not always shared, and safeguarding and complaints were not documented as standing agenda items at both staff and clinical meetings. Staff took patient confidentiality and information security seriously.

Score: 3

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. There was a patient participation group (PPG) who represented the views of people using the service, the practice manager explained that at present, participation was low, and they were trying to recruit new members. We were told that only one member attended the last meeting and although we asked for the feedback link to be shared directly with the PPG members, we did not get any responses.

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 services with community healthcare services.

Score: 2

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. The processes the service used to monitor and review activity did not always give a clear picture of risk. Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted quickly on issues we identified.

The provider could not demonstrate that they routinely audited records.

Staff worked with the primary care network to deliver a wider range of services. The provider told us that they were proud of the work they had done around uptake of childhood immunisations, they had worked with their ICB to produce a training video encouraging children and their parents to get vaccinated which all GP practices in the north central had now implemented.

There was a system in place for staff development through training, supervision and annual appraisals.

Since the assessment, the provider has shown a willingness to improve. For example, following this assessment, leaders submitted a quality improvement plan to improve monitoring processes and told us they had introduced new tools to support staff to deliver high-quality patient care. These changes will be reviewed at the next assessment of the service.