Old Road Medical Practice

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 Outstanding. At this assessment, the rating has changed to Requires Improvement.

The service was in breach of legal regulation in relation to Regulation 17 - Systems or processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards as set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders at the practice were not able to provide us with a clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity, inclusion, and engagement. Staff told us they had not been asked to contribute to any development of a practice vision or strategy. The practice leaders told us they were aware of the projected increase in the local population and was working with the practices in their Primary Care Network (PCN) to address future challenges. However, the practice could not provide an example of any changes or work being undertaken to meet this known challenge.

Staff told us that not all leaders in the practice were approachable and responded to issues and concerns when they raised them. The leaders told us they worked with other practices in the Primary Care Network for the development of primary care services in the local area.

The staff we spoke with told us that although not all leaders were approachable however, they felt able to speak up to management and they would be heard. The practice had a Freedom to Speak up policy to support staff to raise concerns. Staff explained where on the computer desktop the policies and procedures were held to support them at the practice.

We were not provided with evidence that the practice always valued the diversity in their workforce. We were unable to see that they were working towards an inclusive and fair culture by improving equality and equity for people who work for them. For example, the staff records we reviewed showed no recent development or structured appraisals to understand staff needs. However, the practice did have a policy to promote diversity and equality at the practice.

The staff records we reviewed did not contain evidence of clear responsibilities, roles, systems of accountability or good governance. However staff we spoke with told us they understood their individual roles and responsibilities. We found no evidence that leaders met with staff regularly to complete appraisals, supervision, competency checks, or performance reviews. Staff told us they could access the practice policies and procedures on their computer desktop. We were provided no evidence when we requested it that practice leaders held regular meetings with staff, to discuss clinical concerns and emerging risks at the practice.

The practice leaders told us they understood their duty to collaborate and work in partnership however, provided no evidence that they shared information and learning with partners for improvement. Staff told us they worked in coordination with community healthcare services however, evidence of how meetings were conducted and notes taken were not available.

There was no evidence seen at the practice of any focus on continuous learning, innovation or improvement across the practice. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not provide any evidence that they actively contributed to safe, effective practice or research. The practice had no quality improvement plan in place to help drive improvements in services. No evidence of auditing or monitoring work was submitted to us when we requested the practice demonstrate how they were improving and innovating at the practice. There were no examples of clinical prescribing audits to focus on improving prescribing habits or, audit of staff required learning. No risk assessments or IPC risks for example regular handwashing, environmental and legionella water monitoring.