BRENTFORD FAMILY PRACTICE

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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

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. The practice’s mission statement and vision were displayed in the practice to remind staff of the shared goals and staff we spoke to understood these.

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 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.

The service fostered a positive culture where people felt they could speak up, and their voice would be heard. The provider had a Freedom to Speak Up policy which was available to staff. Staff we spoke to said they would access the policy if they needed to. We reviewed the policy and found it detailed both internal and external speaking up arrangements and staff we spoke to knew the arrangements.

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 service had clear responsibilities, roles, systems of accountability and good governance. These were displayed throughout the practice. The provider 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. 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 took patient confidentiality and information security seriously.

The service understood their duty to collaborate and worked in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. The provider worked with other practices within their primary care network to offer extended access. The provider coordinated with community healthcare services where necessary.

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. The practice had implemented a total triage system which was been monitored for effectiveness. They had plans in place with the ICB to expand the reception area and to improve clinical capacity as the practice was currently restricted by space. The provider had proposed to the local council and the ICB the establishment of a Wellness Primary Care Centre to focus on holistic health and well-being and was currently working with a local charity to explore this model of care. The provider had also written to the government for support with this project.

The practice had a quality improvement plan in place to help drive improvements in services. Examples of quality improvement work included medicine audits and cervical cancer screening audits. The latter audits were carried out to improve the uptake of cervical smear screening in women aged 25-49. Following the first cycle and the implementation of some actions, the second cycle of the audit showed an 11% improvement in uptake.