Loddon Vale Practice

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.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.

We found that there were concerns with staff training compliance and oversight, and not all mandatory training was up to date. Some staff immunisation records were incomplete and not consistently documented. In addition, our clinical searches indicated improvements were needed in the monitoring of patients prescribed medicines with specific risks. It meant the provider’s governance systems and processes had not been fully effective to mitigate and address these risks.We found a breach of Regulation 17; Good Governance and this key question was rated as requires improvement.

This service scored 62 (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 engagement, and understanding challenges and the needs of people and their communities.

Visible leadership was demonstrated through structured team meetings, clear communication of expectations and appointment of champions for key areas.

All staff had contributed to the development of the practice vision and strategy. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

We gained staff feedback through a variety of means including interviews and staff questionnaires. We also received 14 completed staff surveys. Feedback we received regarding the culture was positive. Staff told us it was a friendly environment to work in, that the culture was open, transparent, and non-discriminatory. Staff told us they enjoyed working at the practice and there was a strong focus on making sure patients received the best possible care, with all colleagues contributing to a culture where everyone felt valued and respected.

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 was approachable and responded to any concerns raised. Leaders modelled the values of the practice.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Arrangements were in place for staff to speak up internally and the practice were in the process of establishing Freedom to Speak Up arrangements with other practice within the primary care network (PCN).

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. The provider acted on staff feedback and made adjustments to ensure all staff valued.

Policies and procedures to promote diversity and equality were in place. However, we found that not all staff had completed equality and diversity training.

We found there was not always effective oversight and assurance by the practice. For example, the provider’s quality assurance systems did not identify gaps in staff’s mandatory training. The provider had also failed to identify the staff recruitment checks were not completed consistently.

We also found that the practice was not displaying its CQC rating on the premises as required. This was however, immediately addressed following our site visit.

Additionally, our review of clinical records identified that systems and processes in place to monitor patients prescribed high risk medicines were not operating effectively.

Following the site visit, the provider shared with us some evidence of actions completed to address the concerns identified. However, this action was only taken after our intervention and meant the provider’s governance system needed improving and embedding.

We noted there were clear responsibilities and staff understood their roles. Staff could access all required policies and procedures. Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities and managers met with staff regularly to complete their annual appraisals.

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. The practice worked with community and secondary care colleagues to provide joined-up care.

The practice was part of the small 2 practice PCN. Patients of the practice were able to access extended hours appointments throughout the week via rotational arrangement with other practices in the local area.

The provider was committed to continuous learning, innovation and improvement across the organisation and local system. There were learning and educational sessions arranged every month during which clinicians from secondary care were invited to deliver structured learning and share specialist knowledge with practice staff. All staff were encouraged to put forward and test out new ways of working. We however found concerns we reported in the above sections of this report that demonstrate the provider’s own system did not always identify improvements required.