Fell Tower Medical 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 has changed to Requires Improvement.
The service was in breach of regulation in relation to good governance

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 human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
According to the feedback from staff, there was an open and honest culture within the practice. Staff felt confident to raise concerns without fear of retribution and believed that their views were listened to and valued. Staff also said that there was a clear vision for the future.

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.

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 with other practices in the primary care network. There were processes in place for staff to raise concerns where necessary including whistleblowing.

The service valued diversity in their workforce. Leaders ensured 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. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff who had caring responsibilities.

The service leaders did not always have effective governance systems to support oversight of risk, performance, and quality of care. A review of staff records revealed low completion rates for mandatory training. Not all staff members had completed their required training as there were significant gaps in key mandatory training areas such as sepsis, infection prevention and control, Mental Capacity Act and Control of Substances Hazardous to Health (COSHH).

Staff appraisals were documented; however, the service had no formal process for recording staff supervisions. As a result, no formalised records of staff supervisions were available. The provider told us this process was delivered in an informal way. During the assessment, staff files were found to be missing key documents. For example, some files did not have staff proof of identity records, professional qualifications and immunisation records. Some of these staff had been employed for many years. Another documentation gap was identified for a patient living with dementia. Although a capacity assessment was performed during a home visit to inform a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision. This capacity assessment was not officially recorded in the patient's files.

When we reviewed clinical records, we found that some patients had a missed diabetes diagnosis and some patients on thyroxine were overdue for monitoring. The systems in place to support the monitoring of these patients were not always effective.
The service maintained a Patient Participation Group (PPG) to facilitate direct patient feedback. Although the group's engagement led to the successful implementation of a new telephony system, formal meetings were infrequent, and no future meetings were scheduled.
During this assessment, feedback from staff showed they were clear on their individual roles and responsibilities and managers were supportive of staff professional development. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers 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 could work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider worked with other practices within their primary care network to offer extended access and vaccination programmes. Staff took part in meetings within the local primary care network and Integrated Care Board levels. These multidisciplinary team (MDT) meetings were held regularly to support collaborative care planning and ensure continuity of care.

The service focused on continuous learning, innovation and improvement across the organisation and local system. While no formal innovations or research projects had taken place recently, patients were involved in service evaluation through setting up the Patient Participation Group (PPG), patient surveys, regular review and audits.