The Glebe Family 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

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. There was a culture of continuous improvement with staff given time and resources to try new ideas. The service had clear responsibilities and roles. Staff understood their roles and responsibilities. However, improvements were required in some governance systems.

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.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

The service was in breach of legal regulation in relation to the monitoring of vaccine expiry dates and the management of tasks on the practice’s clinical system. We saw the provider took action in response to feedback from the assessment.

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 understood the challenges and the needs of patients and their communities. The service had a shared vision, strategy and culture. Staff spoke positively about the culture of the practice being based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff to develop in their roles.

The service 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. Staff spoke positively about the leaders being approachable and compassionate and provided examples of how they had supported them through difficult times. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns and felt confident they would be listened to.

The service 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. Adjustments had been made to ensure all staff were valued.

Governance systems required strengthening. We found systems were not operating effectively regarding the monitoring of vaccination stock, with 3 vaccines having significantly passed their expiry date. Immediate action was taken by the provider to address the issue. The provider conducted an analysis and investigation during which they confirmed no patient had come to harm. Measures were put in place to strengthen monitoring processes and prevent recurrence. It was acknowledged that time would be needed to fully embed these new measures effectively.

The practice’s clinical task system indicated there were a high number of actions pending that needed attention or completion by staff. A review of a small sample showed action had been taken but had not been marked as completed. The provider conducted a further review of the tasks and identified some duplicates, as well as tasks relating to inactive patients. The provider told us of their plans to review processes to enhance task management and ensure tasks were completed by staff when action had been taken. However, this needed time to be implemented and embedded effectively.

The service had clear responsibilities and roles.

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.

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.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies.

The practice had an active Patient Participation Group (PPG). The PPG and practice staff met face to face to offer support, feedback and develop and review the practice.There was two-way feedback and learning which resulted in improvement to the practice.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

They invested time and resources into listening to people’s experiences and made changes to improve the service. They valued the experiences and contribution of their patient participation group and emphasised the significance of the relationship in driving improvements to the service.

The practice had systems and procedures to ensure that staff learned from past incidents, understood potential risks, and worked to strengthen operational practices or improve staff competencies to prevent future occurrences. There were structured methods in place to identify areas for improvement and to address any issues when things went wrong. Leadership promoted an open environment where staff felt encouraged to speak up, fostering reflection and team-based problem-solving. The practice had a quality improvement plan designed to drive improvement, for example, targeting improvements in medication prescribing.