Dr Onn Syed Also known as Stopgate Lane 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 the leadership, management and governance of the service assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

We assessed all quality statements under this key question. At the last inspection we rated this key question as good. At this assessment the service continues to be rated as good.

The culture, direction, strategy and vision for the service were positive and inclusive with a focus on health inequalities. Staff understood their roles and responsibilities and those of other members of the team and lines of accountability were clear. Staff felt well supported in their role. We noted that some of the processes in place for governing the service and that support the safe delivery of care were not always fully developed or implemented. The provider had implemented processes to improve in these areas in response to our feedback.

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 provider shared a copy of the service strategy and vision for the practice that included a strong emphasis on health inequalities.

Leaders ensured there was a shared vision, strategy and culture that staff in all roles knew, understood and supported. Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted.

The culture of the service was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively.

Staff spoke of a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. Staff described good teamwork and a service that was clear on its function to work in the interests of patients and provide the best patient experience they could. Regular meetings were held for clinical and non-clinical staff. Members of the team told us that communication was effective, and they felt included in decisions about the service.

Leaders were visible and inclusive, and they understood the context in which they delivered care, treatment and support.

The provider worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

Members of the staff team in a range of roles told us that communication across the service was effective.

The provider monitored and acted upon data about outcomes for patients. They made improvements when required.

Feedback from people who used the service was positive with regards to the capability and compassion of the staff and leadership team.

The provider fostered a positive culture where people felt they could speak up without fear of detriment and their voice would be heard and concerns acted upon.

Leaders encouraged staff to raise concerns and promoted the value of doing so. We received completed CQC staff feedback forms and staff told us they felt well supported and confident to raise concerns.

The practice had established ‘freedom to speak up’ arrangements.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by supporting equality and diversity for people who worked for them.

Reasonable adjustments were made to support staff to carry out their roles. Staff with caring responsibilities were actively supported with a flexible approach and changes to schedules to accommodate their needs.

Staff had completed training in equality and diversity and understood how to support people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff.

Some of the processes for governing the service were not clear or effective. For example, the management of incidents, events and safety alerts. Some of the processes for safeguarding required action, which the provider confirmed they had taken following the assessment. Some of the processes for ensuring checks for environmental and equipment safety and infection prevention and control were not fully effective.

The provider used data to monitor and improve performance.

Staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews.

A regular suite of searches of the clinical record system were being run to identify patient needs and ensure these were being met. The provider acted upon our findings with immediate effect to improve patient care in the areas where we found shortfalls.

Staff could access all required policies and procedures. Regular practice meetings were held, during which clinical concerns and emerging risks could be discussed.

The practice used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data and records. Staff took patient confidentiality and information security seriously.

The provider worked collaboratively and in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop effective services.

The practice had a PPG and the provider engaged with them on a regular basis. We met with representatives of the PPG and they told us the provider consulted with them and sought their views on the service provided and developments. Members of the PPG provided highly positive feedback about the service.

There was a focus on learning and improvement across the service. The provider took action to make improvements to the service in response to our findings.

There were regular clinical meetings to discuss patient needs and best practice.

Systems for assessing the quality of the service and outcomes for patients were in place.

The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.