Ashfields Primary Care 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 assessed all the quality statements in this key question. At our last assessment, we rated this key question as good. The rating remains good following this assessment. Leadership, management and governance ensured person-centred care and treatment was provided. We found the provider had clear and effective governance processes, which supported the safe delivery of care. The provider had a vision and mission statement to provide a good quality service that was responsive to the needs of patients. Staff understood their roles and responsibilities and those of other members of the team and lines of accountability were clear. Overall, staff felt supported in their role, able to report any issues affecting the operation of the service and that there was good communication and equality in the workplace. Some staff raised concerns in these areas which have been brought to the attention of the provider to review. The provider supported learning and innovation and worked closely with stakeholders to improve services for patients. Leaders demonstrated that they understood the challenges to quality and sustainability. There were appropriate arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care and treatment provided.

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.

There was a clear mission statement across the service to provide a good quality service that was responsive to the needs of patients. This included an understanding of the challenges and the needs of the patient population. We asked staff to complete a questionnaire to inform this assessment. We had feedback from 28 staff. 61% of staff said they had not been involved in developing the mission statement, vision and values of the practice. The provider told us that plans for the future had been established for each of the teams but that they needed to do more work on the future vision for the service across the teams so that all staff felt involved in this. Leaders and staff could demonstrate positive changes the practice had made to improve the services provided to patients and to improve their experience of working at the practice. There were clear responsibilities for clinical and non-clinical staff. There were arrangements to communicate between and within teams of staff at the service, including regular staff meetings. Staff questionnaires indicated 82% felt that there was a positive, supportive culture at the practice with the remaining staff indicating that improvements were needed. Staff mentioned better working across teams, communication between teams and from the management team and greater recognition for their roles and additional responsibilities as areas where they would like to see improvements.

Leaders understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge and experience to lead effectively. The leadership team worked with other practices in the primary care network (PCN) and were engaged in the development of primary care services within the local area. We asked staff to complete a questionnaire to inform this assessment. Overall, staff told us that leaders were visible and approachable. Members of the staff team in a range of roles told us that communication across the service was overall effective. Some staff told us they would like to see improved communication between teams and from the management team. The provider monitored and acted upon data about outcomes for patients. They made improvements when required. Feedback from people who used the service was positive with regards to the capability and compassion of the staff and leadership team.

The majority of staff who fed back to us told us they could raise concerns about the service, especially in relation to patient care and this would be welcomed. Feedback from staff surveys showed that staff knew how to access policies and procedures and the nominated people to support them to speak out such as the whistleblowing policy and the Freedom to Speak Up Guardian. A minority of staff were not sure about who the Freedom to Speak Up Guardians were. The service had a number of new staff, and the provider told us that they would take further action to increase staff awareness. There were opportunities for staff to provide feedback on how the service was operating. For example, meetings were held, staff surveys circulated and the provider told us how they encouraged staff to approach the management team with any concerns or ideas for improvements. Feedback from the staff surveys showed overall staff felt supported by the management team. However, some staff felt that improvements could be made as they did not feel that the management team were always approachable.

The provider valued diversity in their workforce. They told us how they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Reasonable adjustments were made to support staff to carry out their roles. Staff with caring responsibilities were actively supported with a flexible approach and changes to schedules to accommodate their needs. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. The practice had an equality, diversity, and inclusion policy. Staff feedback indicated that although a number of staff reported a positive culture at the practice, some staff reported that improvements were needed to the practices for promoting equality. This was feedback to the provider to follow up.

There were clear and effective arrangements for governance, management and accountability. A clear management structure was in place with designated staff members who acted as leads for clinical and non-clinical areas. Staff roles, responsibilities and lines of accountability were clear. We saw how information about risk, performance and outcomes were monitored and how change was discussed and implemented following feedback from people who used the service, staff and relevant stakeholders. Information was used effectively to monitor and improve the quality of care and treatment provided. There were effective arrangements for identifying, managing, and mitigating risks. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. There were clear arrangements in place for the availability, integrity and confidentiality of data, records, and data management systems and staff took patient confidentiality and information security seriously. The provider had systems and protocols in place to ensure data and notifications were submitted to external organisations as required.

The provider worked collaboratively and in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop effective services. They worked collaboratively with the primary care network (PCN) and local GP alliance and clinicians from the practice held active roles in both organisations. The practice led on a number of clinical initiatives such as a deep vein thrombosis service and acted as the hub for the region. The practice served as the hub for services for the PCN, including minor surgery and virtual dermatology. The practice had a Patient Participation Group (PPG) and they engaged with the PPG on a regular basis. We met with representatives of the PPG and they told us the provider consulted with them and sought their views on the services provided. The provider was looking at further ways to obtain patient feedback and share information and was in the process of developing a virtual people’s panel. The provider sought feedback from patients and reviewed external sources of feedback such as the National Patient Survey and the NHS Friends and Family Test and took action to address any shortfalls identified. The care-coordinator team acted as a bridge between the practice and the community, supporting patients with accessing services at the practice and they liaised with services external to the practice, such as social services to support patients. The care-coordinator team facilitated information sharing for patients about local health and social care organisations.

There was a focus on continuous learning and improvement across the service. Systems for assessing the quality of the service and outcomes for patients were in place. A number of new systems and processes had been introduced over the last 18 months to improve the service. This included changes to the management of safety incidents, staff support, training and appraisal and to the governance of service provision. The service had introduced a new computer software system to improve the management of patients healthcare needs for both patients and staff. The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality. The practice worked with the integrated care board (ICB) to improve outcomes for patients. For example, a bid had been submitted to the ICB to develop a service aimed at enhancing mental health support and overall wellbeing services for young people.