West Derby 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 assessed all the quality statements in this key question. Our rating for this key question has improved from requires improvement to good. At this inspection we found improvements to the service in relation to staff training and support and arrangements for accountability across the leadership team. Overall feedback from staff was positive. We identified some areas where staff indicated improvements could be made. Leaders told us how they promoted equality, diversity and inclusion. The policies and procedures to support the equality, diversity and inclusion strategies in place should be more comprehensive. There were systems to support the governance of the service and manage risk, performance and outcomes. We identified that some improvements should be made to record keeping to demonstrate that the provider is monitoring the safety of the premises. There were processes to engage with stakeholders such as the Integrated Care Board (ICB), the (Primary Care Network PCN) and patients. However, feedback from the PPG indicated that systems to engage with patients needed further development.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a vision and mission statement to provide a good quality service that was responsive to the needs of patients. This included an understanding of the challenges and the needs of the patient population. We spoke to staff on-site and received 14 staff survey forms we asked staff to complete as part of this assessment. A theme from staff feedback was that staff did not feel involved in the vision for the future. A number of staff were new, and the provider told us that they planned to have a team building day to look at plans for the development of the service and how challenges to the service would be addressed. Most staff told us the culture of the service was positive, open, transparent and supportive. They described staff as working well together and said that they enjoyed working at the practice. Most felt there were sufficient staff. Other responses indicated that staff can feel pressured due to workload, particularly when staff are absent or as a result of staff turnover. Some staff told us that they would like there to more appointments and some indicated they would like more GPs. Staff demonstrated an understanding of equality, diversity and human rights, and they prioritised good quality and compassionate care.

Improvements had been made to the processes for communication amongst the staff team. A variety of meetings and ways to share information were in place. Staff told us that overall, there was good communication. There were clearer responsibilities for clinical and non-clinical staff and staff knew each other’s responsibilities.

The majority of staff told us they felt supported by the leadership team. Staff reported that managers were visible, and the majority said they were approachable and that their feedback was welcomed. Staff gave examples of changes made at the practice as a result of listening to staff feedback. For example, changes to rotas and length of appointments. The majority of staff felt listened to and were confident action would be taken if they expressed concerns.

Leaders were knowledgeable about issues and priorities that could impact the quality of the service. The provider monitored and acted upon data about outcomes for patients. They made improvements when required. Leaders encouraged professional development. Succession planning was in place. Since the inspection in October 2022 the provider had made improvements to the service, which were evident at this assessment.

The majority of staff told us the management team were approachable and supportive and that there was a culture of speaking up where staff felt they could raise concerns and would be supported to do so. The majority of staff told us that they were confident that if they reported concerns, they would be addressed, and appropriate action would be taken. Overall, staff knew how to access policies and procedures and the nominated people to support them to speak out such as the whistleblowing policy and the Freedom to Speak Up Guardian. Three staff were not sure about who the Freedom to Speak Up Guardians were. One member of staff was not aware of the whistle blowing policy. The service had a number of new staff, and the provider told us that they would take action to increase staff awareness.

There were opportunities for staff to provide feedback on how the service was operating. Meetings were held, which included a monthly staff appreciation day, team meetings and a monthly practice protected learning meeting. The provider also encouraged an open-door policy for staff to approach the management team with any concerns or ideas for improvements. We noted that there was not a structured, recorded process to formally seek and record the views of staff and demonstrate any action taken if required.

Leaders told us how they promoted equality, diversity and inclusion. Staff and leaders told us how they would take action to prevent and address any disparities in the experiences of staff, including those with protected characteristics under the Equality Act and those from excluded and marginalised groups.

Staff had completed training in equality and diversity and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. Reasonable adjustments were made to support staff to carry out their roles. The provider supported staff to meet their roles and responsibilities, including flexible working arrangements. We noted that the policies and procedures to support the equality, diversity and inclusion strategies in place should be more comprehensive.

Staff and leaders told us that they were clear on their individual roles and responsibilities. They said that overall, there was good communication, and there were regular meetings which they found useful. Staff could access all required policies and procedures. Staff took patient confidentiality and information security seriously. Staff told us that improvements had been made at the practice over the last 18 months. There were improvements to the operation of the service that supported both staff and patient care and treatment. For example, there was now a more stable staff team in place with less reliance on temporary staff.

The provider had acted on the findings of our last inspection. There were now clear accountability arrangements across the partnership and leadership team. Audits were taking place to monitor patient outcomes. Improvements had been made to staff training and support. Improvements had been made to the monitoring of patients healthcare when they took medicines or had/were at risk of developing a long-term condition that required regular tests and reviews. Improvements had also been made to access to the service. We found that although there were systems in place to support the governance of the service and manage risk, performance and outcomes, improvements were needed. The provider had made changes to telephone access and the appointment system. However, patients continued to express dissatisfaction with access. The provider did not have an effective system to seek, monitor and act on patient feedback and evaluate the action taken. Following the assessment, they reported that they would be carrying out a survey of access by phone and satisfaction with the appointment system. Improvements should be made to monitor the safety of the premises. Checks of water temperature to be undertaken following a Legionella risk assessment were not recorded. The provider told us they had commissioned an external service to carry this out. Although it was evident that action had been taken to address shortfalls from the last infection prevention and control audit, this was not recorded. In-house infection prevention and control audits had also not been recorded. A document to address this was provided following the assessment.

At the last inspection in 2022 the Patient Participation Group (PPG) had been suspended during the COVID-19 pandemic and the practice was in the process of re-establishing regular meetings with the PPG. At this assessment we met with representatives of the PPG who told us they met every three months and that the membership was small. They told us that the main issues for patients were getting an appointment, getting through to the practice by telephone and continuity of GPs. The PPG told us that the practice listened to their concerns but that they could be better informed about the action and planned action to address them. The PPG told us that there had been improvements to access.

The provider understood their duty to collaborate and work in partnership with other stakeholders. Staff and leaders told us how they worked in partnership with key organisations to support care provision, service development and joined-up care.

The practice worked with the local Primary Care Network (PCN) to deliver services to meet the needs of patients. The Integrated Care Board (ICB) told us that they met with the provider to review the operation of the service and strategies to meet the needs of the patient population.

Staff and leaders engaged with partners and used local networks to identify new or innovative ideas that could lead to improvements in outcomes and experience for people who used the service. There were processes to engage with patients and to listen to their views and keep them informed about practice developments. For example, a newsletter had been introduced. However, feedback from patients indicates that these systems need further development.

Staff told us that overall, there was a focus on continuous learning and improvement across the service. Staff told us they were supported to develop their knowledge and skills. Opportunities for staff to speak up with ideas for improvement and innovation where provided. The majority of staff felt that their views were listened to and were acted upon. Staff gave examples of changes made as a result of the management team listening to them such as changes to the rotas and increased appointment times.

The provider worked with stakeholders to improve services for people within the locality. This included being involved in ways of delivering equity of experience and outcomes and providing good quality care and treatment for people. There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence. Improvements where needed to ensure all staff were informed about complaints received and any learning.