Ambrose Avenue Group 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.

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 at the practice told us about their vision, strategy, and culture. However, staff did not feel they had been involved in any of the processes to develop the strategy and culture with leaders.

The patient participation group told us they had not been told about the practice vision, strategy or culture at the practice or been told about changes occurring at the practice. Following the onsite CQC assessment, we were provided assurance that GPs and leaders would attend the meetings and a set agenda with practice updates would be part of the standard agenda.

The practice leaders understood the context and local practice demographics in which they delivered care, treatment, and support; aligned with the practice culture and values. Leaders had the skills, knowledge, experience, and credibility to lead the practice.

The practice leadership team worked with the other practices in their Primary Care Network (PCN) and were engaged in the development of primary care services within the local area.

Staff told us leaders at the practice were approachable and responded to concerns raised.

The staff we spoke with told us leaders were approachable, and they were able to speak up and believed 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. However, not all staff we spoke with knew who the speak-up guardian was at the practice. They told us the leaders encouraged staff to speak with them before raising concerns, which was confirmed in the practice policy.

We were told there were processes in place to support workforce equality, diversity, and inclusion, for the well-being of staff. Leaders told us that staff were offered reasonable adjustments to support them at work if required and developed a wellbeing programme for staff.

Staff gave examples of support provided, for instance training and development and flexible working hours. Staff had completed equality and diversity training appropriate for their role.

The staff we spoke with told us they felt valued by their team leaders for the work they carried out at the practice.

The practice had lead responsibilities, roles, and systems of accountability for governance.

Leads were identified in a range of areas which included for example, clinical services, clinical training, prescribing, safeguarding, and infection control. Staff were supported to manage and deliver sustainable care, treatment, and support. Staff acted on the best information available regarding risk, performance, and outcomes, which was shared securely with others when appropriate.

The practice held an improvement action plan that recorded the active and completed plans for future sustainability of governance management.

We observed staff had regularly received appraisals and performance reviews. Staff could access all required policies and procedures to support them in their roles at the practice.

The practice understood their duty to collaborate and work in partnership, to ensure services worked seamlessly for people.

They shared information with healthcare partners and engaged and collaborated with their Primary Care Network (PCN) practices to improve primary care service provision to the local population, for example, extended access appointments. Representatives from their PCN confirmed the practice was fully engaged and collaborated with them, exploring services for the future to improve patient health.

Feedback from the care homes was positive. Care home staff told us the practice worked with them to meet the needs of their residents. They told us there was a dedicated telephone line to contact the practice for urgent and timely access.

Since their registration with the CQC this year, the practice had focused on improvement and development of a comprehensive action plan to keep them on track. We found internal communication and effective structured practice meetings had been introduced, for example partner management meetings, clinical and multidisciplinary meetings, palliative care meetings, team and departmental meetings. This has had a positive impact to strengthen in-house communication and supported teamwork at the practice.

Clinical reporting and audits were undertaken on a continuous basis to identify areas for patient outcome improvement.

The practice improvement plan had been developed to drive their future goals for example, to deliver quality patient care, create a resilient stable workforce and leadership, autonomous governance and a training and development programme.

All the staff we spoke with told us that leaders encouraged training and development and the practice was using new technology to improve the ways of working.

The practice had acted on feedback from people following the introduction of their online booking system, and provided people support to book online appointments on their behalf.