Penvale Park Medical Centre

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. 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.

Leaders had developed a shared vision,strategy and culture. This was based on transparency, equity, equality, engagement, and understanding challenges and the needs of people and their communities. Staff were encouraged to keep their knowledge and skills up to date in line with continued professional development to support the service. Leaders informed us there was a strong emphasis on the safety and well-being of staff.

The practice 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.Staff recognised improvements made to the leadership approach in the months leading to our assessment.Leaders had the skills, knowledge,experience and credibility to lead effectively. They did so with integrity,openness and honesty.

The practice had recently joined the primary care network and were in the early stages of developing effective relationships with other practices to support the delivery of high-quality care.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns and felt confident they would be dealt with appropriately.Leaders discussed actions taken in response to staff feedback to improve.

The practice 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 practice 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.

Leaders told us they engaged regularly with services to which they made referrals, seeking feedback on the quality and appropriateness of those referrals. There was no evidence to show that the practice worked or had established relationships with other practices to share and improve outcomes. However, staff views and concerns were encouraged, heard, and acted upon to help shape the service and its culture. Leaders acknowledged that they were still in the process of building relationships with other practices and expressed optimism that these partnerships would strengthen over time.

The practice 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 within the service. The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.