The Everglade 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 the service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At the last inspection in November 2022, using our old methodology, we rated this key question as requires improvement. We were not assured there were appropriate governance systems and processes in place to ensure safe infection prevention and control measures were in place; emergency equipment and medicines remained in date and safe to use; policies were reviewed to ensure they remained up to date and relevant; documented supervision of the nurse prescriber; and the safe administration of the rotavirus vaccine. At this assessment, the rating has changed to good because the previously reported issues have been reviewed and improvements put in place.

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.

The practice had a shared vision, strategy and culture that focussed on learning and development which prompted trust and understanding. Staff listened to patient’s needs, complaints and suggestions and showed an understanding of equality, diversity and human rights in providing safe, compassionate care for the patient population. The staff understood the vision of the practice to meet the needs of the patient population and to review the care when these needs changed. The culture at the practice was open and staff were trained.

The service had inclusive leaders at all levels who understand 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 were approachable and responded to any concerns raised. Staff also told us that 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 practice had established freedom to speak up arrangements with other practices in the primary care network. Details of who to contact externally was on display in each room in the practice and staff knew the process to speak up.

The service valued diversity in the 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. Adjustments had been made to ensure all staff were valued. Team building and social events occurred frequently.

The service had clear responsibilities, roles, systems or accountability and good governance. They used this to 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. Staff received regular appraisals and performance reviews. Governance processes were established that were appropriate for the service. Staff could access policies and procedures on the shared computer network. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. However formal minutes were not held for clinical meetings. Notes and actions were placed on individual patient records but there was no system to ensure all patients were followed up. Managers also conducted informal meetings on a frequent basis. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider worked with other practices within the primary care network to offer extended access, and flu and covid vaccination programmes.

The practice prioritised patient clinical care and need by ensuring that allied professionals were used effectively in response to feedback from patients. Learning was shared with other practices and the wider primary care network. The practice nurse networked with other practice nurses across the local area. The practice worked well with its own patient participation group. The practice was involved in regular community events to help educate patients and raise the profile of services available in the practice.

The service focussed on continuous learning, innovation and improvement across the organisation. 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 a quality improvement plan in place to help drive improvements in service. This focussed on improving patient access to appointments and the cervical screening and childhood immunisation programmes. Quality improvement audits were carried out regularly.