Upper Thames Medical - The Park Surgery and Lechlade Medical

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 assessed all quality statements in the well-led key question. This is the first inspection of this service since its registration with CQC. At this assessment, we rated the key question as Good. The practice had a clear vision and strategy to deliver high quality care and promoted good outcomes for people. Staff were clear on their individual responsibilities and knew who was accountable for each aspect of the service. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Leaders had oversight to ensure the effective running of the service and were capable, compassionate, and inclusive. The practice encouraged the duty of candour, openness, and honesty. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles.

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.

Leaders demonstrate detailed vision and values for the service. Staff told us they felt engaged by leaders at the service. Staff felt listened to and contributed to the development of the service. Staff were encouraged to keep their knowledge and skills up to date in line with continued professional development. Leaders informed us there was a strong emphasis on the safety and well-being of staff. Regular meetings kept staff up to date with any changes or progress the service had made.

Staff told us leaders were visible, approachable and genuinely cared about them. Leaders were aware of the challenges of delivering good quality care and were striving for improvements. Leaders understood the challenges to quality and sustainability and demonstrated the skills and knowledge required to influence others and understand their role in leadership. Leaders included staff in their planning for the future. The service had identified the actions needed to address challenges and make improvements.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. The practice learned and made improvements when things went wrong. Representatives from the Patient Participation Group (PPG) commented the service took concerns seriously and proactively made improvements. Complaints were shared with the PPG who told us they felt the service was open, honest and transparent in the sharing of information. People felt supported to raise concerns and staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong, staff understood how to raise concerns and report incidents both internally and externally. Staff told us learning from events and incidents was shared in both clinical and non- clinical meetings with the wider staff teams. Staff told us leaders were approachable and promoted an open, non-blame culture. Policies and procedures supported and promoted a learning culture. Leaders demonstrated they managed significant events and complaints appropriately and staff were involved in identifying learning and making changes that improved the care and treatment for people and embedded good practice. There was a system to monitor incidents and complaints. This included undertaking an investigation into the cause and actions identified to address the concerns.

The practice actively promoted equality and diversity. Staff had access to an equality, diversity, and inclusion policy and had completed relevant training. Newly recruited staff completed a monitoring form, so the service was aware of the diversity of their workforce.

The service had clear responsibilities, roles, systems of accountability and good governance. Leaders and managers supported staff, and staff we spoke with were clear on their individual roles and responsibilities. They acted on information about risk, performance and outcomes, and shared this securely with others when appropriate. Effective processes were followed for managing risks, issues, and performance. The practice had established systems, processes, policies, and procedures for managing staff performance issues. They also engaged an external Human Resources (HR) company to provide expert advice and support in this area. There was evidence of systems and processes for learning, continuous improvement, and innovation. Staff were encouraged to attend meetings where updates and new information was shared. Actions from meetings was recorded and accessible to all staff. Staff took patient confidentiality and information security seriously. Staff had access to all policies and procedures. However, oversight of the environment was not consistent. We observed not all areas were locked as per the practice policy, such as clinical rooms when not in use. The practice provided evidence following the on-site visit that these concerns had been addressed. Recent changes to the management team were still embedding at the time of the inspection. Managers we spoke with demonstrated an awareness of this and were receptive to receiving feedback from staff regarding their experiences. Staff provided examples of when they had approached the management team with concerns which demonstrated they were listened to and action taken.

Staff recognised there had been changes within the management team and structures. We received many positive comments regarding the support provided by leaders. Staff worked with stakeholders to build a shared view of challenges and of the needs of the population. Leaders told us they engaged with services they referred to regularly for feedback on the quality of referrals. Staff and external partners' views and concerns were encouraged, heard and acted on to shape the service and culture. The service had regular engagement meetings with both commissioners and partner organisations in the area.

The service worked within a multi-disciplinary team to provide the right support for everyone. The service actively participated in regular meetings where people’s care and treatment needs were discussed to improve their outcomes. There was a focus on continuous learning and improvement. The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements. Managers made sure staff received training and supervision, to maintain high quality care. However, we found that staff had not received regular appraisals in line with the practice appraisal policy. Following our on-site visit, the practice provided assurances and supporting evidence that all staff had appraisals scheduled, and that an appraisal schedule had been implemented. The practice had recently gone through a period of transformation and new systems and processes continued to be embedded. For example, health and safety audits, recruitment processes, appraisals and improvements to the environment.