Norvic Family Practice Also known as Victoria Health 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 assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 75 (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 practice had a mission statement which highlighted that it strived to provide good quality, patient centred care in a friendly and professional manner.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Staff reported a positive experience of working at the practice. Team members highlighted effective communication and stated that they felt included in decision making processes relating to the service.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

Regular meetings were held with staff, and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

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 that their wellbeing was considered, and their views respected, and concerns acted upon. 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 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.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve. Staff we spoke with were aware of how to access the freedom to speak up guardian and were encouraged to share concerns with the 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.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, and revalidation. There was an induction process in place for newly appointed staff, and staff told us that they were well supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available.

The service had clear responsibilities, roles and systems of accountability. Governance processes were established; however, some areas required further strengthening to ensure risks were consistently identified and managed,these included the monitoring of infection control processes and the actioning of safety alerts.

Staff could 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 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. Managers met with staff regularly to complete appraisals and performance reviews.

The practice carried out regular audits to monitor service provision and improve the quality of services provided. For example, medicine related audits, access, complaints and significant events.

The service understood the importance of working in partnership with other organisations and community stakeholders to support people and improve services. They shared information and learning with partners and collaborated to deliver services that met local needs.

Leaders told us they worked with stakeholders and the local community. The practice was part of a Primary Care Network (PCN) which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

The practice offered flu and covid vaccination programmes. Staff had made adjustments and collaborated with local services to further support community healthcare services. For example, rooms were provided for the drug and alcohol service so patients could access this service locally.

The practice had a patient participation group (PPG) with one meeting having been held in the last 12 months. We received mixed feedback from patients we spoke with in the PPG, who told us the care they received from the GPs was generally very good, but accessing the service could be difficult. They also highlighted the lack of involvement of the leadership team with the patients to discuss changes or new initiatives. We were told that patients had not been made aware of the new triage system when it was being implemented. A PPG open day had been held and the current PPG members had not been involved. Feedback received by the CQC prior to the onsite assessment had been positive from patients, with comments on the care and support they had received.

The service focused on learning 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 clinical team reviewed clinical guidelines and carried out regular audits to ensure patients received quality sustainable care. For example, the practice had completed an audit to identify patients and carry out a targeted intervention for patients with poorly controlled diabetes who may not be taking their prescribed medication. The search identified 18 patients with HbA1c levels above 75 mmol/mol who appeared not to be receiving diabetes medication. A review of the patients’ records was completed which showed patients had been prescribed the appropriate medicines, but they had not requested or collected their medications within the previous 90 days. The pharmacists were reviewing each patient and selected patients were booked in for assessment with the specialist diabetes nurses. Ongoing monitoring and follow-up were planned to evaluate improvements in medication adherence and glycaemic control.

The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community. This included providing access to a social prescriber and other community services as part of the primary care network.

The leadership team held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided to share information with the whole team quickly to mitigate future risks.