The Acocks Green 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 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 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.

All staff had contributed to the development of the practice vision and strategy, which was keptunder review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. The provider included staff in discussion with us about the areas identified for improvement . They told us that they are a collaborative service and would collaborate with staff to ensure that the vision of the service is understood by all. The service is part of a wider GP partnership provider which uses lessons learnt from other practices to ensure that a positive culture of improvement and direction is shared.

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 were visible and knowledgeable about the service they provided, and generally demonstrated the skills and experience required to lead effectively . They did so with integrity, openness and honesty. Staff told us leaders in the practice was 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 Health and Beyond Partnership group and were engaged in the development of primary care services within the local area.

The service did not always foster a positive culture where people felt they could speak up and their voice would be heard. The Freedom to Speak Up Guardian (FTSU) role was held by a non-clinical partner within the parent organisation, which was not aligned with good practice due to a lack of independence.

We raised this with the provider, who acknowledged the concerns and took prompt action to establish an alternative arrangement with a local provider. Evidence of the revised arrangements was provided during the inspection period. The provider had a freedom to speak up policy; however this policy did not identify the risk of having an internal FTSU guardian which could stifle honest and open discussions by staff. The provider told us that the new FTSU guardian arrangements would be reflected in an updated policy. We saw that staff meetings were taking place regularly, with staff able to discuss concerns, both professional and personal either in a group setting or one to one with the management team. We were told that informal discussions about patient needs occurred regularly, where staff asked for advice and guidance from senior colleagues.

The service strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people 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 staff who had caring responsibilities.

The service did not have fully effective governance systems to ensure clear roles, responsibilities and accountability. Oversight of risk, performance and outcomes was not consistently robust, and information was not always used effectively to drive improvement or shared appropriately.

We identified gaps in governance oversight, including the absence of key emergency medicines such as naloxone, ineffective systems to verify locum staff training and immunisations, and health and safety audits that had not identified environmental risks such as issues with emergency pull cords and seating in the reception area.

In addition, arrangements for Freedom to Speak Up were not aligned with good practice, as the appointed guardian was not independent. 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 practice was part of a GP partnership which shared knowledge and systems. Communication systems and oversight were effectively cascaded from leadership to practice level. Provider policies and procedures were robust and had clear lines of communication to staff as required.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with partner organisations to deliver the flu and covid vaccination programmes. Staff had coordinated care with community healthcare services, including utilising clinical pharmacists employed by the practice to increase take-up of vaccines such as flu and covid.

The service did not always focus upon continuous learning, innovation and improvement across the organisation and local system.

While the provider had developed a quality improvement plan informed by areas such as the GP patient survey data. The systems for learning, improvement and innovation were not sufficiently effective to drive sustained change. This was evidenced by low uptake of immunisation and cervical screening. There were gaps in recruitment checks including locum staff training and immunisation status.

Not all recommended emergency medicines were in place, and this had not been risk assessed and health and safety audits were ineffective in identifying environmental risks. Patient survey data continued to show poor access, and information was not consistently available in other languages, demonstrating that learning had not been effectively used to improve outcomes or meet the needs of the practice population.