Grovelands Medical Centre Also known as Dr D.A. Riley & Partners

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 understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. While governance systems were generally effective, however the inspection identified a small number of areas where oversight needed strengthening, particularly around prescription stationery.

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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

All staff had understood the practice vision and strategy, which was kept under review. Strategic planning within the practice was informed by patient feedback, workforce intelligence and service performance data. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges, supporting research activity and eventually improving patient outcomes.

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.

All the staff members we spoke with were positive about the culture of the practice. Staff told us it is a friendly environment to work in, the culture was open and transparent, and they enjoyed working there. In addition to speaking with staff, CQC received written feedback from 24 members of staff. All staff reported a good team spirit amongst colleagues and felt the practice was well organised.

Staff told us leaders in the practice was approachable and responded to any concerns raised. The leaders modelled the values of the practice. 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. There were clear policies in place, and staff knew how to access them if they wanted to raise a concern formally. Regular team meetings gave further opportunities for staff to talk openly about their experiences.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The service valued diversity in their workforce. They work 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. Leaders told us staff wellbeing was recognised as a priority, with leaders providing access to support, supervision and development opportunities.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

Leaders actively contribute to local service development and shared initiatives across the network.

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. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures.

We identified gaps in practice’s oversight and management of prescription stationery, including a lack of effective audit. At the time of the inspection, systems and processes in place did not provide sufficient assurance for the secure storage, tracking and reconciliation of prescription stationery. However, there was no evidence of material impact on patient safety. Following the inspection, leaders advised us that an immediate review of prescription stationery governance arrangements had been initiated.

We found that some of the Patient Group Direction (PGD) had not been appropriately authorised and signed by clinical staff. This was immediately reviewed and rectified while we were onsite.

A backlog of patient records requiring summarisation was identified. The provider recognised this issue and was taking steps to strengthen oversight and administrative capacity.

Leaders demonstrated a commitment to strengthen governance arrangements in response to identified risks, to ensure systems were robust and compliant.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The provider was developing a neighbourhood-based approach to care delivery, recognising the importance of integrated working in addressing local health inequalities and improving health outcomes for patients.

Staff had made adjustments to improve coordination of their service with community healthcare services, including through established regular meetings centred on the care of those at higher risk of hospital admission.

The service had effective mechanisms for gathering patient feedback. There was an active Patient Participation Group (PPG) that met quarterly to contribute to service development.

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 actively contribute to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements. Leaders used a range of engagement mechanisms including patient surveys, Friends and Family Test, staff feedback and PPG involvement to make improvements to the service delivery.

Staff told us there were regular protected learning time (PLT) sessions which offered shared clinical learning.

The practice had recently adopted a new triage system moving from Total Triage to GP Triage to improve access and prioritisation. Staff feedback suggested there was a clear vision for the practice supported by collaborative working, along with continuous learning and improvement.