Al-Fal Medical Group - Pikes Lane 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

This is the first inspection for this service since its registration with CQC. This key question has been rated as good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Al-Fal Medical Group - Pikes Lane Medical Centre had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement and an understanding of the challenges and the needs of people and their communities.
Staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the stresses in the local population.
Both clinical and non-clinical staff who gave feedback highlighted aspects of the service culture as being patient focussed and making sure systems in place supported working in partnership with patients to deliver high quality and patient centred care.
Staff commented that being honest, fair and respectful were key aspects of the culture of the service. This was towards patients, stakeholders and colleagues.
 

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 that 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.
Leaders were proactive in seeking out partner agencies and organisations that would support them in promoting the best outcomes, services and amenities for people who used the service. Leaders also demonstrated a willingness and ability to share best practice and learn from other providers within the area.
 

People did not always feel they could speak up and that their voice would be heard.
The practice had only recently established Freedom to Speak up arrangements with an external party within 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. We saw senior leaders had addressed concerns related to discrimination.

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 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 work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.
The provider worked with other practices within their primary care network to offer extended access and flu and COVID-19 vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.
Staff had improved some of their services by working with community healthcare services; for example, staff discussed signposting and referral to local programmes for diabetes and obesity management, which were a significant health need for the local population.

Al-Fal Medical Group - Pikes Lane Medical Centre 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.
The practice had a quality improvement plan in place to help drive improvements in services. This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working.