Tramways Medical Centre - O'Connell Also known as Tramways Medical Centre (Dr J O'Connell & Partners)

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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to 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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. They did not always understand the challenges and the needs of people and their communities.

The practice’s aim was to offer high-quality holistic care to their patients, incorporating the best possible clinical care from their doctors and nurses and a friendly efficient service from their reception and administration staff.

It was not clear how leaders monitored and reviewed progress against the delivery of their strategy. The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years and worked with partner agencies to address these challenges.

In the absence of a policy, it was difficult for staff and leaders to actively promote equality and diversity and work to identify the causes of any workforce inequalities.

They demonstrated a positive and compassionate listening culture that focused on learning and development. On the day of our sight visit, leaders were receptive and open to areas that we highlighted as needing improving. They acted promptly to offer assurances in those areas.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have sufficient established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service. For example, systems for safe recruitment and safe staffing and systems for monitoring environmental risks. Some of the individual issues we observed on the day of our site visit seemed to stem from a systematic failure of governance rather than attributed to individual or human error.

Staff we spoke with were clear on their individual roles and responsibilities. However, where there was clarity - and policy supporting this, some systems failed due to individuals not following policy and process. For example, where there were safeguarding concerns about a patient, a lack of overarching governance and oversight meant that there were delays in reporting, decision making and documenting outcomes and actions, which was not in line with the provider’s own safeguarding policy.

Policies and standard operating procedures were difficult to find. We saw evidence that many could only be retrieved from performing a lengthy search of digital folders. The provider told us that some staff struggled with information technology and were not able to perform the search for the document easily themselves. Policies were not kept together in a centralised place. There was no version control, and policies did not always contain the most up to date guidance.

Leaders supported staff but it could not be evidenced how regularly they met with them to complete appraisals and performance reviews.

Clinicians held regular partners meetings and clinical meetings, during which they discussed emerging risks and potential improvements to the service. There were not always clear actions that arose from these meetings, in the sample that we reviewed, and there was no evidence as to how these minutes or actions were shared with staff.

Staff needed to make improvements as to how they took confidentiality and information security seriously. We found an unsecured NHS Smartcard during a tour of the building. We asked to review the provider’s confidentiality policy, but this was not retrievable or available. A review of significant events indicated that leaders had not submitted a statutory notification to the Care Quality Commission, regarding the death of a patient, as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.