HMC Health Feltham

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment in 2021 using the old methodology, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a shared vision, strategy and culture that focused on learning and development which promoted trust and understanding. The staff listened to patients’ needs, complaints and showed an understanding of equality, diversity, and human rights in providing safe and compassionate care for the patient population. The staff understood the vision of meeting the needs of the patient population and to review the care when the needs change. The practice was keen for it to be a local family orientated practice. The culture at the practice was an open-door one where all staff were encouraged to share their concerns. The practice was also projecting to increase the space available to treat the patients as the space was currently limited. Most of the staff were trained within the practice and up-skilled to encourage learning and development.

The practice had inclusive leaders who were supportive of their staff to deliver patient care that was compassionate and showed the ethos of the practice. Staff told us that the leaders were very present and listened to their concerns. The practice had a succession plan that involved the senior GPs, and the medical director and other GPs stepping up when the need arises. Clinical / administrative meetings were attended by the leadership and administrative team to share relevant information to promote good culture to address concerns quickly. The practice worked together with the local primary care network to cater to the needs of the local community.

The practice encouraged the staff to share their concerns. Staff knew to share their concerns with the leadership, however, there was no whistleblowing policy in place and no named freedom to speak up guardian. The practice had a poster in the staff work area that stated how to raise concerns, but no individual was named as a freedom to speak up guardian. The practice explained that they were working together with the primary care network to ensure there is a named freedom to speak up guardian.

The practice trained staff on equality and diversity. Flexible working was available for staff and risk assessment completed for staff who required it. Reasonable adjustments were made to support staff in need of them.

The practice clearly recorded actions from monthly clinical and administrative meetings and shared them with staff. Staff respected patient confidentiality and information security. Staff had regular appraisals and performance reviews. Staff could access all required policies and procedures, however most of them were out of date and needed to be reviewed while others needed to be created. Leaders supported staff and were clear in their roles and responsibilities. The medical director and the clinical team with the operations and business managers acted on current information about risks, performance and outcomes. Staff records did not show compliance with accessible information standards training.

The practice collaborated with other healthcare professionals in partnership to provide care for the patient population and shared information to promote learning and improvement. The practice continued to promote continuous improvement by acting on complaints and feedback received. The practice did not have a patient participation group (PPG) because it was difficult for the practice to get the patients to be involved. The practice was working with the primary care network to ensure the patient voices were heard. The practice prioritised patient clinical care and needs by ensuring that allied professionals were used effectively in response to feedback received from patients. Learning was shared with other practices and the wider primary care network. The practice nurse networked with other practice nurses across local area.

The practice operated on extended hours clinic in collaboration with the primary care network to support and ease patient access. The practice was working to improve patient engagement. Lessons learnt from significant events, complaints and any feedback received were shared with the practice staff for improvement works. Quality improvement audits were carried out regularly.