Alum Rock 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 carried out an announced assessment of 7 quality statements: 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 and Learning, improvement and innovation. We found:

Since joining the practice in 2022 and then taking over in 2023, the new GP partners had identified some areas for improvement and acted to improve the quality of services being delivered. However, we found significant issues the provider was not aware of with, particularly with recruitment and safeguarding processes.

The provider was aware that the premises needed improvement and this was impacting on infection prevention and control and had developed plans on how to improve this, however, there was no confirmed date for when building work would commence.

Leaders were aware of the needs of their patient population and the challenges they faced in delivering high quality care however staff were not always supported to deliver care that was safe, integrated, person-centred and sustainable, and that reduced inequalities.

Leaders did not have effective oversight over governance and management systems.

We found breaches of the legal regulations in relation to good governance. Systems were not effective in identifying, mitigating and monitoring risk related to patients and staff including safeguarding process, recruitment and ongoing training checks, medicines management and infection prevention and control.

We have asked the provider for an action plan in response to the concerns found.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All staff we spoke with shared the provider’s desire to deliver high quality patient-centred care. Leaders and practice staff understood their patient population, their cultural needs and challenges.

Staff told us it was a positive workplace, where they felt well supported by their leaders.

However, not all staff demonstrated a well-developed understanding of equality and diversity, or how to prioritise safe, high-quality, compassionate care.

The provider’s vision was to provide high quality accessible care in a safe, responsive and courteous manner. The provider had developed values that would help them achieve this vision. However, during this assessment, we found these values were not well embedded amongst all staff, systems and processes that had been implemented were not effective in helping the provider achieve the vision or values.

Leaders did not always demonstrate they had the experience, capacity and capability to ensure that the organisational vision could be delivered and risks were well managed.

Leaders were visible and accessible and staff told us they felt supported to deliver safe and effective care. However, leaders did not always demonstrate they understood all risks to delivering safe and effective care and they were not aware of some of the risks that we identified during the assessment.

The practice did not have safe or effective recruitment processes or systems to monitor compliance with ongoing required training.

The provider did not have effective systems in place to collect and record information relating to staff immunisations status. We saw it had been identified on the IPC audit in April 2024 that hepatitis B status was needed and the action was marked as completed on the IPC action plan. However, there was no consideration given to other immunisations that may be needed. We also saw that within the audit it was marked that all relevant immunisations status had been collected and this was not marked as a concern that needed action. During the assessment, from staff files we viewed, we found that all relevant immunisation information had not been collected.

Leaders were not knowledgeable about all issues that would affect their priorities for delivering high quality services.

Leaders had not implemented processes so that they would be alerted to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff.

The provider did however take appropriate action when we raised concerns with them during the assessment.

Not all staff we spoke with understood the concept of a freedom to speak up (FTSU) guardian.

Staff did not know who the FTSU lead was either within or outside the practice.

All staff we spoke with told us they felt they could raise concerns with leaders and felt that they would be listened to.

The provider had not implemented a freedom to speak up policy.

Staff told us they had a diverse workforce that met the needs of their patient population.

All staff had appraisals and were supported to develop.

Staff we spoke with felt supported by leaders and did not feel discriminated against.

The practice had a diverse workforce that was made up of permanent and long-term locum staff.

Leaders took active steps to ensure staff and leaders were representative of the population of people using the service.

There was some evidence of leaders engaging with staff to drive improvements. However, the provider did not formally seek staff views on culture so that improvements could be made.

The provider sent us evidence of 4 workstation assessments for non-clinical staff. Of these assessments, 2 had been completed after our site visit. We saw that 2 staff had identified issues with their workstations and equipment and 2 staff had reported suffering health issues as a result of using the computer at work. We did not see evidence of action being taken to support staff.

There were leads for most clinical and non-clinical areas. Staff we spoke with were clear on their individual roles and responsibilities and on who leads were. However, there was confusion about who the lead was for infection prevention and control.

Managers met with staff regularly to complete appraisals and performance reviews and clinical staff reported they always had support from GPs.

Staff had opportunities to discuss incidents, complaints and safeguarding concerns as well as complex patients. However, there was no formal monitoring to ensure that learning following complaints and incidents was embedded or that actions had been successful.

Leaders did not have clear oversight over all governance systems and processes.

The practice staff met monthly to discuss issues such as incidents, complaints, performance and safeguarding concerns.

There were governance processes in place to ensure that patients were monitored and reviewed in line with guidelines and that staff responded to safety alerts.

There were processes in place to ensure that most risk assessments related to the premises were carried out and that equipment was safe to use.

However, the provider could not demonstrate they had effective oversight over all governance processes to identify, monitor and manage all risk and performance issues. Specifically with safeguarding, recruitment and ongoing training checks, infection prevention and control and responding to patient feedback.

We found that healthcare assistants received ongoing support from clinical staff, however, there was no formal monitoring of their documentation in patients’ records. Although we did not identify any concerns with their assessments of patient’s needs’, we did find concerns with records not being coded correctly.

During our assessment we identified other concerns with coding of records. Leaders told us formal audits were not carried out to monitor that coding by non-clinical staff was carried out correctly.

Generally, policies were reviewed and updated. However, not all had version control or dates when they were implemented. Where policies did have version control, it was not easily identifiable to staff what the changes were.

Safeguarding policies did not contain up-to-date information on required training.

The chaperone policy was not wholly appropriate.

The infection prevention and control (IPC) policy was not comprehensive and did not support effective management of IPC.

The policy and processes to refer to the antenatal (midwife) service had no dates or version control on them indicating when they had been implemented or last reviewed.

The modern slavery and human trafficking policy was not practice specific.

Patient feedback was mixed.

The website was not kept updated to keep people well informed

The patient participation group (PPG) representatives we spoke with were positive about leaders and that they worked with them to improve services.

Staff worked with the primary care network (PCN) to deliver services to a wider population of patients.

Feedback from the PCN included that the practice made good use of the extended hours appointments available to them.

The provider had reviewed patient feedback information however they had not developed action plans following the national or in-house patient surveys or following friends and family test feedback to improve services and patient satisfaction.

They did not monitor or respond to patient feedback left on the NHS or Healthwatch websites.

There was no analysis of trends or patterns in complaints.

Leaders told us they supported the development of their staff.

Staff discussed and learnt from complaints, incidents and audits.

Staff worked with the primary care network to deliver a wider range of services and with the patient participation group to improve existing services.

Leaders told us they had improved processes to become more efficient, for example they had reviewed and improved the process for issuing repeat fit notes . They had also implemented the duty GP triage process and they had increased the clinical team.

Receptionists had received care navigation training and signposted patients if they were not able to offer an appointment.

The provider told us they were updating the website to improve access and information available to patients. They also told us of their plans to improve the premises although no date for building work to commence had been confirmed.

Leaders had processes to report and learn from incidents and complaints. However, the provider could not demonstrate how they used this information to monitor trends and if actions they had implemented had been effective.

There were different ways for people to provide feedback however the provider could not always demonstrate how they used this feedback to make further improvements.

The practice was a training practice for trainee GPs. We saw evidence of feedback from one trainee and the provider told us they displayed feedback from trainees and students on a notice board in a staff area for staff to view. Feedback we viewed was positive about clinical staff and the training they received.

Staff were supported to review performance and develop further. However, the provider could not demonstrate that they routinely audited records to ensure good record keeping including coding so that they could identify further training needs and to ensure that care and treatment was being delivered safely.

The provider did not have effective processes in place to monitor staff training in line with national guidelines and their own policies.