Albrighton Medical 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

At our last assessment, we rated this key question as outstanding. 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.

The service was aware of the needs of their population and adapted to changes in a proactive way. Staff shared experiences and expressed a clear understanding of the service vision Meetings regularly occurred where all staff were included and able to speak freely on their ideas and thoughts.

The culture observed was open, honest and caring. This emanated from leaders and all staff, who were very sincere and passionate about safe care. Feedback from service users reflected this, describing the service as kind, going above and beyond and very community focused.

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 service were approachable, supportive and kind. Staff also told us leaders modelled the values of the service. We saw the leadership team worked with other services in the Primary Care Network (PCN) 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.

Staff described how they felt comfortable and confident to speak to leaders regarding concerns. The service had established Freedom to Speak up arrangements which were available in the policy, and access to an independent freedom to speak up guardian, although staff we spoke to were unclear on who the freedom to speak up guardian was, those we spoke to had not had reason to go to them and had felt comfortable to raise concerns within the service leadership team.

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 and staff had received training. There were procedures in place to ensure work was equitable across the team.

The staff members shared experiences which showed they felt they were treated fairly and their wellbeing was taken into account. All staff had opportunities for development and were encouraged to seek out ideas and courses themselves as well as those suggested by their line manager.

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. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Paper patient records were not kept in a secure way, there was no restricted access in place. A risk assessment had not been completed to mitigate risks and consider additional measures or actions. The patient record storage was a temporary measure and we were shown evidence of a continued plan for digitalisation. Following our on site assessment we have received confirmation that actions had been taken and the storage was secure, restricted with a risk assessment completed.

We found patient identifiable documentation awaiting shredding and disposal in unsecure storage. This was brought to the attention of the service who immediately secured and disposed of the documentation and have since provided staff with refresher training on data security as per the policy and clinical rooms not in use will be locked.

Leaders and managers provided effective support to staff, all of whom demonstrated a clear understanding of their individual roles and responsibilities. Regular appraisals and performance reviews were conducted to support professional development. Staff had access to all necessary policies and procedures. Managers held meetings with staff, and any resulting actions were clearly communicated and accessible. There were gaps identified in the consistency of processes and actions, such as actions and learning from safety alerts and events, and investigations into complaints required more clarification in some examples we reviewed.

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

Feedback provided showed the service had good relationships with various stakeholders, such as care homes, community support groups and the local hospice. There was evidence of multidisciplinary meetings with other service services.

The service worked with other services within their primary care network to offer extended access and actively lead and contributed on pilot projects and schemes.

The service also worked closely with other local service services, such as pharmacies, in a collaborative and supportive way.

Community support groups described the service as supportive and kind. There was evidence of the service being an active part of the community. The service actively participated in community events and activities such as talks to local schools and community support groups and took part in community meetings.

The service had an active and supportive Patient Participation Group (PPG) that met regularly and told us that the service was open, honest and approachable. The group had purchased equipment for the service through fund raising and were included in development of the website and leaflet. The group meetings were well attended and included regular talks from staff and other health care professionals.

The PPG Chairperson was an active supporter of the community and was fundraising to maintain local face to face access to citizens advice bureau within the service building.

The service encouraged 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 service and research.

The sharing of learning from significant events was not completed in a timely effective way, with inconsistent details within records. This was acknowledged by the service and changes have already been made to rectify this.

Staff were given opportunities for attending team events, learning and career development.For example staff told us about progression into other roles and attending courses for development.

The service actively contributes to safe, effective service and research, including pilot schemes such as the heart failure at home and research projects with a number of stakeholders.

There was a clear ethos of continuous improvement involving stakeholders. The service is a training service linked to a university as well as offering clinical support to local healthcare professionals to allow development and collaboration.