Queenstown Road 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 Good. At this assessment, the rating remains the same.

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 practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

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 were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. 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 practice had completed a staff survey in April 2024. We saw evidence of feedback collation and the actions the practice had since taken to address staff concerns.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements within the practice and with other practices in the PCN, as well as. Staff were aware of how to raise concerns, and who concerns should be escalated to.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for staff who work for them.

Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

The practice did not have fully effective systems in place to monitor patients prescribed certain medicines. The practice also did not have effective systems in place to ensure the emergency medicines stock was checked on a regular basis and remained safe for use. The practice had ineffective systems to monitor staff who were overdue, or had not completed, training.

The service had clear responsibilities, roles and systems of accountability. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

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 provider had established governance processes that were appropriate for their service. 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.

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 provider worked with other practices within their PCN to offer extended access, and flu and Covid vaccination programmes.

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 patients. They actively contribute to safe, effective practice and research.

All staff were encouraged to put forward and test out new ways of working, and we saw examples where the practice’s clinicians had collaboratively designed flowcharts to guide the management and monitoring of blood pressure in those with both pre-existing and non-pre-existing diagnoses.

The practice had enabled a feature on their telephone system which allowed patients to check and cancel their appointment without needing to speak with a member of staff.

The practice made use of innovative technology to support service delivery. For example, the practice had started using an artificial intelligence transcription service to assist with the documentation of complex clinical notes, as well as introducing an automated recall software system to send out invites to patients who were due monitoring.

The practice did not have an active Patient Participation Group (PPG). The practice previously had a PPG with two members; however, they made the decision to disband this as it was not representative of the patient population demographic. The practice reported that they had struggled to recruit additional members, particularly since Covid-19.