The Groves 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 Inadequate. At this assessment, the rating has changed to Good.

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.

It had developed an Equality and Diversity Policy, with the expressed purpose to “to set out the aims of Groves Health to create an inclusive working environment, where access to work is based on fair and objective criteria, and where there is zero tolerance of unlawful discrimination in respect of our workforce, patients, visitors and others involved in providing or receiving our services”. The practice was actively engaging with that process and no such concerns were raised by staff or patients in feedback we received.

The service had taken action to improve since our last inspection. For example:

• It had implemented a functioning programme of one-to-one meetings for all staff. In addition, staff participated in regular annual appraisals.
• The practice complaints policy referenced the practice Duty of Candour Policy and linked to the CQC myth buster which set out the responsibilities of the duty of candour.

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.

Since our last inspection, the practice had taken action to deal with the concerns raised, these included:

• The practice now had written scope of practice documents for all non-medical prescribers. These were reviewed during one-to-one meetings to ensure the agreed scope remained appropriate.
• During this assessment we looked at the training records for a range of staff. These were effectively fully up to date.
• The practice had taken action to ensure that the information available to staff booking appointments correlated with the scope of practice relevant to each of the clinicians.

Staff told us leaders in the practice were approachable and responded to any concerns raised. 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. It had a Speaking Up policy which actively encouraged staff to raise concerns. There were internal and external contacts listed within the policy.

Staff said there were no barriers to speaking up and their views were listened to and acted upon. This aligned with the management approach of being actively engaged with staff to seek their views.

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. Leaders were proud that staff spoke a range of languages and so were available to assist patients in need of translation services and other diverse needs.

We did not receive any negative feedback from practice staff in regard to equality, diversity and inclusion. Staff said they felt supported by management and worked as part of a team.

The practice had a mission statement, recruitment policy and induction policy and procedures for new starters. These and other policies and procedures were embedded within the running of the practice, and set out the practice’s vision in relation to its staff, ensuring all were equally treated and had access to opportunities for progression.

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. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had taken on board concerns and issues raised at our last inspection and had introduced a range of changes, including, acting on omissions in recording staff immunity status, ensuring policies and procedures aligned with actions in running the practice, resolving conflicts between recorded scope of practice and actual practice of staff in advanced clinical roles.

It had, since our last inspection, fully implemented the online triage tool. This had been welcomed by many patients, some of whom commented on this to CQC. Other patients, including those without access to the internet, were less pleased with the system. The practice had taken steps to ensure access to services for such patients by allowing patients to phone or attend in person to book appointments.

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

At this assessment we received feedback from 2 members of the Patient Participation Group (PPG). The PPG meets 2-3 times a year with meetings organised by the practice. They found the practice to be open and honest and listened to concerns raised by PPG members.

Patients told us that staff at all levels were enthusiastic, hard-working and patient focussed. Patients considered there were enough qualified staff, they had enough time during appointments, felt involved in their treatment, and were given options for treatment of issues. They also told us they were able to get appointments with their preferred GP, though this might involve a delay.

Previous concerns about the online triage system for allocation of appointments were still a concern to some patients. The practice worked to make patients aware of the alternative ways of booking appointments. Other patients had embraced the online system and found it worked well to enable them to book appointments

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 improved its handling of significant events, including ensuring information was shared with relevant staff, since our last inspection.

The practice had worked with its patient population to increase membership of its Patient Participation Group (PPG). New members had been recruited from a range of age groups and ethnic backgrounds, to ensure a greater diversity of patient views.