St Johns Wood 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 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 in August 2017, we rated this key question as good. At this assessment, the rating has changed from good to requires improvement. The service was in breach of Regulation 17, related to good governance because we found issues with the effectiveness of the processes to monitor clinical and administrative tasks in the course of primary care delivery.

This service scored 61 (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. Staff understood the direction and culture of the service to be patient-focussed and high-quality care. Staff told us that the GP partners are very focussed on continuity of care for the patients.

Staff told us leaders in the practice were approachable and responded to any concerns raised. The leaders informed us that they worked with the primary care network and were engaged in the development of primary care services within the local area. The practice ensured an open-door culture where staff could raise concerns. However, the leaders were visibly absent during the site visit to offer support to the staff during our assessment process. The responses to the assessment feedback had not shown the leaders as being proactive to respond to concerns and mitigate the risks identified.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements with another practice in the primary care network. Staff were aware of how to raise concerns internally and externally.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. Staff who worked at the service were multiculturally diverse and multilingual which helped with the patient population.

The service did not always have clear responsibilities, roles, systems of accountability and good governance. This was related to administrative and clinical oversight, effectiveness of the processes or systems, as revealed by the evidence obtained during the assessment process. During the site visit, we found that there was no effective system to track staff training. In addition, the leaders were unable to show us that regular audits of emergency equipment and medicines were completed to identify any gaps in the inventory. There was a lack of oversight of building maintenance checks completed by the landlord and any action plan related to ensure the safety of staff and patients. Some of the practice policies were not specific and needed to be reviewed, such as the safeguarding policy. Safeguarding policies were in place but not specific to the practice; the policy stated that staff training should be yearly but the practice staff completed training every 3 years.

Not all the staff were aware of the practice policies, for example, induction of new clinical staff did not embed awareness of all relevant policies such as medical emergency response policy. This was identified during the last assessment in August 2017 for staff to be aware and understand updated practice policies.

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 collaborated for improvement. The service worked with the patient population including the patient participation group (PPG) to improve service delivery in conjunction with community health services and the primary care network.

The service did not always focus 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. The provider was not always proactive in improving the quality of the service received by the patient population through audits of systems and clinical audits. There was no evidence that 2-cycle audits were completed as part of quality improvement work. The provider worked with the local primary care network to improve primary care delivery. Following our feedback on the clinical searches, the service followed up on the patients with specific concerns that were identified from our assessment. However, there was no indication that there had been wider learning about their systems or approach.