Albion 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

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

We rated this key question as requires improvement. Leaders and managers did not have full oversight of systems and processes to promote effective and safe service provision. We found that systems to deliver safe care were not always effective, in particular, health and safety, infection prevention and control, medicines management and staff training.

This service scored 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. All staff we spoke with shared the provider’s desire to deliver high quality patient-centred care and foster a strong partnership with patients to achieve the best possible health outcomes.

Leaders and practice staff understood their patient population, their cultural needs and challenges. Staff told us it was a positive workplace, where they felt well supported by their leaders. However, improvements were needed to training provision to ensure that staff were well supported and received appropriate training and development.Since the assessment, the provider informed us they have introduced regular mentorship sessions where supervision, consultation reviews, and learning needs are recorded and followed up to support clinical staff development.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The service had developed values that would help them achieve this vision. The values included asking patients about their ideas, concerns, expectations and providing patients with effective and timely diagnosis and treatment. Most staff demonstrated a well-developed understanding of equality and diversity, and how to prioritise safe, high-quality care. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Leaders and managers did not always demonstrate they had the experience, capacity and capability to ensure that the organisational vision could be delivered, and risks were well managed.

Leaders were visible and accessible, and staff told us they felt supported to deliver safe and effective care. The leaders told us they operated a no-blame learning culture which would provide all staff with an open and equal working relationship. Leaders we spoke with understood the importance of protecting individuals from discrimination and promoting equality in the workplace. The service had recently signed up for Pride in Practice training, to create a more inclusive environment for LGBTQ+ staff and patients. However, leaders did not always demonstrate they understood all risks to delivering safe and effective care and they were not aware of some of the risks that we identified during the assessment. For example, we identified fire safety risks and infection control risks during the assessment. The provider did however take appropriate action when we raised concerns with them during the assessment.

Since our assessment, the provider informed us of improvements they have made in response to our findings, in relation to governance and management of risks. We will review these at our next assessment see if they are effective and have become embedded into practice.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff we spoke with said they would feel comfortable in making their views heard. Most staff had completed whistleblowing training and there was a whistleblowing policy in place. Although leaders told us they had not carried out a staff survey, we saw staff had been given the opportunity to speak up and give feedback in minutes from team meetings. There was evidence of action taken in response to concerns or feedback given.Since our assessment, the provider has informed us that they have carried out a staff survey to better understand the views and experiences of staff who work at the service.

Information about the freedom guardian was available as a poster in staff areas. A member of the local Primary Care Network acted as the independent freedom to speak up guardian for staff to speak 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 felt valued and respected. The provider offered flexible working options to accommodate staff needs and time for staff to follow their religious and cultural beliefs. Leaders took steps to ensure staff and leaders were representative of the population of people using the service.

Most staff had access to continuing professional development, support and mentorship. Leaders provided training and resources to ensure staff were aware of their rights, including those related to equality, dignity, and respect in the workplace. Staff had completed equality, diversity and inclusion training. The practice had an employee assistance programme which provided advice and counselling.

Staff we spoke with told us they felt confident that their concerns and ideas resulted in positive change to shape services and create a more equitable and inclusive organisation. There was some evidence of leaders engaging with staff to drive improvements. However, the provider did not formally seek staff views on culture so that improvements could be made. For example, leaders told us they had not carried out staff surveys. We saw staff were given the opportunity to speak up and give feedback through regular appraisals and supervision sessions and specific staff group meetings.Since our assessment, the provider has informed us that they have carried out a staff survey to better understand the views and experiences of staff who work at the service. Leaders had also introduced regular mentorship sessions where supervision, consultation reviews, and learning needs are recorded and followed up to support clinical staff development.

We found the provider did not have clear and effective governance processes, which supported the safe delivery of care. The provider did not always have clear responsibilities, roles and systems of accountability. The processes in place were not effective and did not ensure that recommendations from most risk assessments related to the premises were carried out and that equipment was safe to use.

The leader’s oversight of safety systems needed strengthening to ensure staff always followed policies. Systems for responding to medicines safety alerts required improvement. Leaders did not have effective oversight to ensure prescribers followed the prescribing policy. Generally, policies were reviewed and updated. However, not all had version control or dates when they were implemented. Where policies did have version control, it was not easily identifiable to staff what the changes were.

There were leads for most clinical and non-clinical areas and staff knew who the leads were. However, some staff we spoke to were not clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews and clinical staff reported they always had support from GPs.

Staff had opportunities to discuss incidents, complaints and safeguarding concerns as well as complex patients. However, there was no formal monitoring to ensure that learning following complaints and incidents was embedded or that actions had been successful. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Practice meetings were held monthly for all leads and partners. Nursing teams meetings were held weekly and admin team meetings every month. The practice held daily huddle meetings where all staff could attend. Leaders said this assisted with the general oversight of managing the practice.

Staff took patient confidentiality and information security seriously. Leaders were prioritising succession planning and leaders told us the service were recruiting for a new GP Partner, as a partner planned to retire in the next few years, to ensure the continued delivery of high-quality care.

Leaders acknowledged the safety concerns we identified during the assessment and took them very seriously. After the assessment, the provider informed us of actions they had taken to strengthen governance processes. We will review these at our next assessment of the service.

The staff understood their duty to collaborate and work in partnership, so that services work seamlessly for people. The practice carried out referrals to secondary care. The practice was involved in community engagement with the local mosques. There was a patient participation group (PPG) who represented the views of people using the service, the practice manager explained they were trying to recruit new members. We spoke with a PPG member who told us the practice had made improvements, and the management team were responsive to their feedback. There was active liaison and open and transparent collaboration with relevant external stakeholders and agencies.

The patient participation group (PPG) representatives we spoke with were positive about leaders and that they worked with them to improve services. The provider told us that there continued to be strong links and engagement with the PPG and the wider community.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services.

The provider had reviewed patient feedback information and developed an action plan following the national GP patient survey and following friends and family test feedback to improve services and patient satisfaction. Staff responded to patient feedback left on the NHS Choices website. There was some analysis of trends and patterns in complaints.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. The service had management team meetings monthly to review the strategic direction, values, staffing and update on organisational priorities. However, the processes the service used to monitor and review activity did not always give a clear picture of risk. Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted quickly on issues we identified.

Staff were supported to review performance and develop further. However, the provider could not demonstrate that they routinely audited records to identify further training needs and to ensure that care and treatment was being delivered safely. The provider did not have effective processes in place to monitor staff training in line with national guidelines and their own policies.

Staff discussed and learnt from complaints, incidents and audits. Staff worked with the primary care network to deliver a wider range of services and with the patient participation group to improve existing services.

Leaders told us they had improved processes to become more efficient, for example they had implemented the duty GP triage process and receptionists had received care navigation training and were able to signpost patients if they were not able to offer an appointment. The provider told us they were updating the practice website to improve access and information available to patients. They also told us of their plans to improve the premises although no date for building work to commence had been confirmed. Staff told us they felt proud to be a training service. The senior partner was a qualified GP trainer.

Since the assessment, the provider has shown a willingness to improve. For example, following this assessment, leaders submitted a structured quality improvement plan to improve monitoring processes and told us they had introduced new tools to support staff to deliver high-quality patient care. These changes will be reviewed at the next assessment of the service.