Alderwood 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’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff were unaware if a long-term vision for the development of the service was in place and staff had not contributed to the development of a service vision and strategy. Some staff told us they had no idea what the future of the practice held or the direction they were travelling in.

We received mixed staff feedback regarding the culture within the practice. Some staff were positive about the culture stating it was honest, open and leaders were approachable. Staff felt able to raise concerns with leaders and the partners. However, some staff did not feel that concerns they raised were always listened to or acted on. For example, staffing levels. Some staff expressed concerns the service structure was hierarchical, there was a reluctance to take on new ideas and team working needed to be strengthened. For example, regular staff meetings were not in place for staff to collectively discuss issues within the practice or for updates to be provided. Whilst staff enjoyed their jobs, some staff reported that morale was low.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities.
 

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not always have clear responsibilities, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Established governance processes in relation to the quality statements we reviewed during this assessment were not always in place. In particular, systems to gain assurances from the landlord that required risk assessments for legionella, fire, gas, electrical and fire alarm testing and drills were carried out on a regular basis and issues were addressed. Systems to ensure equipment was calibrated in a timely manner were not in place. Systems for ensuring security within the building needed to be reviewed. In particular, the secure storage of clinical waste and cleaning products; ensuring clinical and consultation doors were locked when rooms were not in use; the secure and safe storage of patient records. Health and safety risks were not always completed and a risk log was not maintained. For example, risk assessments to mitigate risks when a complete record of staff immunisations against potential health acquired infections were not in place; the safe storage of oxygen; how risks from non-wipeable chairs would be mitigated until they were replaced; how patient paper records stored on the floor would be protected against fire, water leaks and sunlight.

Systems were not in place to monitor staff compliance with actions identified on the infection prevention and control action plan. Systems to ensure note summarisation and coding and scanning of patients’ records were not in place. Staffing levels had not been reviewed in response to audits that identified peak demand times for phone access to the practice. Some appraisals were out of date, evidence of clinical supervision for non-medical prescribers was not available and systems to ensure staff training was up to date required strengthening.

However, most staff we spoke with were clear on their individual roles and responsibilities.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.