Salisbury Avenue Healthcare

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

There were clear responsibilities, roles and systems of accountability to support good governance and management. Leaders demonstrated that they understood the challenges to quality and sustainability and had taken actions necessary to address them.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us they had an open-door policy, and staff feedback was that leaders were approachable. Staff said if they had any concerns, they felt safe to raise them and would be listened to. When patients were affected by things that went wrong, they were given an apology and informed of any resulting action. There was an emphasis on the safety and well-being of staff. There were transparent processes to manage behaviour that were inconsistent with the vision and values.

The practice had a clear vision and credible strategy to provide high-quality, sustainable care. Its culture supported this vision. Leaders demonstrated that they understood the challenges to quality and sustainability, and effective systems monitored progress with action plans. Leaders had weekly meetings to ensure effective governance through a set agenda and implemented change when appropriate.

Staff said that leaders listened and were approachable, they felt safe raising concerns, and they enjoyed working in a friendly environment.

The practice had policies and procedures which supported the learning culture. The practice offered apologies to people, learned lessons from individual concerns and complaints, and took action to improve the quality of care. Staff had clear roles and responsibilities and were flexible in these roles to meet patients' needs.

Leaders informed us they encouraged an open culture, and they had an open-door policy. Staff told us the practice had an open and honest culture. They knew who to contact and felt comfortable expressing any concerns.

The practice had a Freedom to Speak Up Guardian and had implemented the NHS Freedom to Speak Up policy for NHS healthcare providers.

Staff felt empowered and were confident that their concerns and ideas resulted in positive change to shape services and created a more equitable and inclusive organisation.

Systems and processes ensured clear responsibilities, roles, and accountability structures to support the workforce. The systems strongly emphasised staff well-being. The practice had a diverse workforce. Equality and diversity training was part of the mandatory staff training.

All practice policies were on the practice’s computer system, and staff knew how to access them. Leaders told us that the practice reviewed policies annually. Named leads were in place for key areas, and staff were clear about their roles and responsibilities.

Our clinical searches on the practice’s clinical system showed good patient care and follow-up processes; however, some processes required review. For example, we looked at five out of 473 recorded medication reviews carried out in the last 12 months which did not contain any detail about the content of the review. We noted that reviews on previous dates did contain appropriate information. The practice had a business continuity plan and business development plan, and we saw evidence of these being used effectively. There were adequate arrangements for identifying, managing, and mitigating. There were arrangements for the availability, integrity, and confidentiality of data, records, and data management systems. As part of the inspection, we asked to provider to send us a range of information deducting private details where necessary. On one occasion the provider emailed a document which they attempted to redact; however, the method used was not wholly effective. We discussed this with the practice and was assured they would investigate what had occurred.

We found staff and leaders were open and transparent, and they told us they collaborated with all relevant external stakeholders and agencies.

We saw evidence of the practice leaders working in partnership with key organisations to share learning that resulted in continuous improvements to the service. They used networks to identify new ideas that could lead to better outcomes for people. The practice had effective working relationships with its Primary Care Network (PCN), mainly using additional staff through the additional roles reimbursement scheme (ARRS) to improve patients' access to care.

The practice had a learning culture in which staff and leaders actively participated. Staff talked positively about their experiences of joining the practice, moving to new roles, and receiving ongoing support and development. Leaders informed us that they benchmark their performance with the other practices within the PCN, engage well with the Integrated Care Boards (ICB), and meet quarterly with their Patient Participation Group (PPG). The minutes of these meetings are available to the public on the practice’s website under ‘Services’.

We observed evidence of shared learning and staff involvement at all levels. Comprehensive assurance systems were regularly reviewed and improved; this included risk assessments and learning from safety alerts and significant events. Clinical and internal audit processes positively impacted quality governance, with clear evidence of actions taken to resolve concerns. There was evidence of systems and processes for learning and continuous improvement. The practice had an effective process to manage medicines safety alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA). There were transparent processes for monitoring the stock of emergency medicines and equipment, and our observations confirmed that the processes were followed. The practice had a system to allow people to speak up when they had concerns, which was underpinned by a policy. The staff we spoke to were aware of the process and felt confident raising concerns if necessary.