Ellergreen 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 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 good. At this assessment, the rating remains the same.

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 practice promoted a positive and compassionate culture that supported trust and understanding between staff and patients using the service. Learning and development were supported.

The provider understood the challenges and needs of people and their communities and collaborated with partner agencies to support people effectively. Staff who provided feedback through our staff questionnaire or during our onsite assessment described the culture of the service being positive and teamwork being good. However, some staff commented that they had not been involved in developing the mission statement, vision, and values.

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 were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

Leaders encouraged staff to raise concerns and promoted the value of doing so. The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Staff who provided feedback through our staff questionnaire or during our onsite assessment felt supported and confident to raise concerns. Staff had clear safe routes to raise concerns, there was a whistleblowing policy, and staff had been provided with access to a freedom to speak up guardian to better promote transparency, trust and psychological safety within the workplace.

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, for example we saw adjustments to support staff working patterns were in place.

The service did not always have effective governance, with clear, accountability, and risk management processes. Risks were not always acted on appropriately. For example, failing to notify CQC promptly about changes, events or incidents that affected the service or the people who use it. We discussed this observation during our onsite assessment and again post assessment. The provider was receptive to our feedback. We received assurance that a Significant Event Analysis (SEA) would be undertaken to ensure policies relating to the reporting of incidents to CQC were reviewed and strengthened and learning from the (SEA), would be shared across the practice and with CQC.

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 recorded actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The provider demonstrated a clear commitment to collaboration and partnership working to ensure services operated seamlessly for patients. They worked with other practices across the North Liverpool PCN to offer extended access and engaged in joint initiatives to drive improvement. For example, the practice carried out work to improve identification and management of patients at risk of osteoporosis to ensure patients were identified, treated and monitored.

Leaders and staff were proactive in sharing ideas and using good practice to improve care. They regularly listened to feedback from patients and the community, using it to shape and assess new ways of working. Staff had time and support to build their skills in improvement and innovation, and there was clear evidence of this being put into practice. Everyone was encouraged to come forward with ideas and take ownership of change.

The service worked within a multi-disciplinary team to provide the right support for patients. The service actively participated in regular meetings where people’s care, and treatment needs were discussed to improve their outcomes. There was a focus on continuous learning and improvement within the service.