Drs Patel and Partner Also known as Vassall 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 inspection, we rated this key question as good. At this inspection, the rating remains good, although the need for some improvement in governance was identified.

The service was in breach of legal regulation in relation to good governance. This is because patients prescribed high-risk medicines were not always monitored in line with national guidelines, and clinical entries made by clinicians at the service were not sufficiently clear.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders detailed clear vision and values for the service. This was shared with staff who they told us had input into the direction of the service. Staff told us that they felt engaged by leaders. They told us that they were listened to, and detailed examples

of how they had contributed to the development of the service. Staff were aware of and understood the vision, values and strategy and their role in achieving them.

The service had a realistic strategy and supporting business plans to achieve priorities. The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population. The provider monitored progress against delivery of the strategy.

Staff told us that leaders at all levels were visible and approachable. They told us that they worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

There were clear lines of responsibility to support capable and inclusive leadership. The practice had put in place clear job descriptions and parameters for all staff and had ensured staff were aware of their roles and responsibilities.

However, we found that leaders did not always make sure that medicines and treatments were safe or ensure that an effective a system for monitoring patient safety alerts was in place.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. There was freedom to speak up policy in place at the service. Staff told us they understood how to raise concerns and were confident that the leadership of the organisation would act on them. The service had a freedom to speak up guardian nominated in their policy. However, neither leaders nor staff knew who it was. Following the assessment, the service provided refresher training for all staff.

Leaders told us that the service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff told us that they felt equality and diversity was respected by leaders and the service.

Staff had received equality and diversity training. Leaders provided an environment free from discrimination and harassment, where staffs contribution was valued, and they were protected from abuse.
 

The service had procedures in place to monitor high-risk medicines; however they were not always followed. We found that not all prescribed medicines were being monitored in line with the services own policies and procedures or nationalguidelines, and clinical entries made by clinicians at the service were not sufficiently clear.

As part of the clinical searches, we reviewed 10 records where either medicines or dementia reviews had been undertaken. In four of these records there was no detail as to what had been reviewed with the patient and/or carer.

Managers met with staff regularly to complete appraisals and performance reviews. Staff knew where to 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 we spoke to demonstrated that they took patient confidentiality and information security seriously.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. However, staff we spoke to said there was sometimes a delay in receiving support when requested.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.
The service had a patient participation group, although they told us that they had struggled to recruit to the group, and there were only 2 or 3 regular attendees.
 

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.

The practice had a quality improvement plan in place to help drive improvements in services. This focused on improving patient experience.