Anchor Medical Practice Also known as Netherton Health 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

At the last inspection we found the practice did not have a fully embedded governance system, there was a lack of oversight in relation to staff training and recruitment.At this assessment, we found that the provider had taken action to address areas of governance and had effective processes in place to monitor staff were up to date with training relevant to their role. However, we found further improvement was required in relation to the supervision of staff in advanced clinical roles to ensure their prescribing competencies were monitored.

We found that there was effective leadership in place and the practice had designated roles for areas of accountability. Staff and patient feedback demonstrated the practice involved the public, staff and external partners to sustain high quality and sustainable care.

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.

There were systems to ensure compliance with the requirements of the duty of candour and processes in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

Staff told us that there was a positive culture and there was effective communication and staff felt supported by the leadership team and felt able to raise concerns without fear of retribution. There was an open culture and clear learning within the practice. Regular meetings were held with staff and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

The practice had a realistic strategy and were reviewing their supporting business plans to achieve sustainability. This included the recruitment and retention of staff and the continued engagement with the community and stakeholders.
 

Staff described the practice team as supportive and the management team was visible and approachable. Leaders understood the challenges to quality and sustainability and had effective business plans in place to ensure there was capable and effective leadership, this included plans for the development of staff as part of their succession planning.

The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue. There were regular meetings held with staff and staff told us they encouraged to report incidents to identify ways in which the practice could continually improve. All staff had undertaken equality and diversity training.

There was an equality and diversity policy in place, this supported the provider to ensure their staff team reflected the community in which it was based. The service valued diversity in their workforce. The provider had systems in place that promoted a working environment that was fair and equitable. They had regular staff meetings and there was a clear organisational structure. We were told that there was an emphasis on the safety and well-being of staff. Staff said they were treated fairly and there was an open-door policy.

There were policies and procedures in place for the safe recruitment of staff which had been reviewed further since our last inspection. Other policies included recruitment, equality and diversity, bullying and harassment and grievances. All staff had completed equality and diversity training and had access to regular appraisals, one to ones, coaching and mentoring, clinical supervision and revalidation. There was an induction process in place for newly appointed staff with regular reviews and opportunities to feedback through team meetings and 1-2-1 conversations.

Staff told us that practice policies were accessible, and they were clear about their roles and responsibilities and felt supported by the management and clinical team. All newly appointed staff had completed an induction and training and had opportunities through training and development to improve their job skills.

At the last inspection the provider failed to undertake effective risk monitoring and we found some of the systems in place to be ineffective. However, during this assessment we found some improvements had been made to mitigate risk and to support governance structures and systems. However, we found the management of risk required further strengthening to ensure risks were mitigated. For example, we identified a safety alert that had not been actioned appropriately and staff not directly employed by the practice were not being supervised appropriately to ensure the the prescribing of medicines was in line with national guidelines. We found people on medicines with the potential to cause addiction were not being advised of the risks and patients with long term conditions were not being monitored. For example: People with hypothyroidism were not receiving the appropriate monitoring, however prescriptions continued to be issued with no evidence that a review had taken place to ensure the medicines prescribed needed reviewing.

A business continuity plan was in place which gave guidance to staff for the preparation of major incidents. We found that policies contained clear information about the designated lead in areas such as infection, prevention and control and safeguarding. All staff were aware of the designated leads in these areas. The practice had policies in place for sharing information with third parties, for example PCN staff.
 

Leaders told us they worked with stakeholders and the local community. The practice was part of a primary care network (PCN) which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

Leaders told us they had a patient participation group (PPG), and meetings were held every 3 months. There were 8 active members. During the on site assessment we met with some of the PPG members who told us how they engaged with the practice and the improvements the practice had made. This included changes to the current building and encouraging patients from diverse backgrounds to join the group to ensure there was a mix of different cultures. The feedback received was positive on how changes were communicated and how the group was kept up to date with the latest information.

At the last inspection we found improvements were needed to ensure systems and processes were effective. At this assessment we found recruitment processes, systems to record staff immunisation and staff training updates had been implemented. All newly appointed staff had completed a programme of induction and training which was reviewed by leaders to ensure training was monitored and kept up to date.

Regular practice meetings were held to share learning and to review quality improvement activity to drive improvements. We saw evidence to demonstrate that the outcomes from significant events or complaints, were shared with staff to promote learning and mitigate future risks. We found that processes were in place and the practice had carried out a number of targeted quality audits and used information about care and treatment to make improvements.