OHP - College Green Medical Practice

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: There was an inclusive and positive culture of continuous learning and improvement. This was based on meeting the needs of people who used services and wider communities, and all leaders and staff shared this. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. Overall, leaders had implemented effective governance and management systems. Where we identified gaps, we raised this with leaders during the assessment, who took immediate action to review systems and provide assurances that reduced the level of risk. Information about risks, performance and outcomes was used effectively to improve care.

This service scored 86 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders ensured there was a shared vision and strategy and that staff in all areas knew and supported them. All staff understood how their role helped in achieving them. Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service and was focused on learning and improvement. Staff at all levels had a well-developed understanding of equality and diversity, and they prioritised safe, high-quality, compassionate care. All staff we spoke with shared the desire to grow, develop and deliver high quality patient-centred care. Staff told us it was a positive work place, where they felt listened to and supported by their leaders.

Leaders ensured that the vision, values and strategy had been developed and reviewed through a structured process in collaboration with staff. Staff and leaders ensured any risks to delivering the strategy, including relevant local factors, were understood and had an action plan to address them. They monitored and reviewed progress against delivery of the strategy and relevant local plans. The practice had developed an Equality and Diversity topic page on their internal information sharing system where all staff could see the specific projects the practice was involved in to raise awareness and to improve access and experience for vulnerable groups. There was an ongoing internal staff training program that included focussing on how practice staff could be aware of groups of populations where there may be inequalities in access to health care and how they could promote better access for these groups to their services leading to better health outcomes. Training planned for September 2024 was focussing on veterans and LGBTQ+.

Leaders had the experience, capacity, capability and integrity to ensure that the organisational vision could be delivered and risks were well managed. Leaders at every level were visible and led by example, modelling inclusive behaviours.

High-quality leadership was sustained through safe, effective and inclusive recruitment and succession planning. Leaders were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. Leaders had 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.

Staff and leaders acted with openness, honesty and transparency. Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and complete learning events. All staff were confident that they would be listened to and action would be taken. There was a culture of speaking up where staff actively raised concerns and staff felt supported to do so. Leaders told us their Freedom to Speak Up Champion,played a vital role in ensuring that staff could confidently raise concerns.

The practice had policies and processes in place that supported staff to speak up when they identified concerns. When concerns were raised, leaders investigated sensitively and confidentially, and lessons were shared and acted on. When something went wrong, staff received feedback and were told about any actions being taken to prevent the same happening again.

Leaders took action to review and improve the culture of the organisation. Staff told us they had a diverse workforce, this was embraced and used to deliver high quality services. All staff had appraisals and/or personal development plans and were supported to develop and access relevant training. Staff we spoke with felt supported by leaders and did not feel discriminated against.

The practice had a diverse workforce and demonstrated fair and equitable recruitment procedures. Leaders took active steps to ensure staff and leaders were representative of the population of people using the service. Leaders ensured there were effective and proactive ways to engage with and involve staff. The practice offered flexible working hours for staff. Leaders told us they had received positive feedback from staff regarding their flexible working arrangements and that offering flexible working hours had a positive impact on retention and staff wellbeing.

Leaders and managers supported staff to deliver high quality, patient centred care. All staff we spoke with were clear on their individual roles and responsibilities as well the roles and responsibilities of others. Managers met with staff regularly to complete appraisals and performance reviews. Staff had opportunities to learn from audits, incidents and complaints and to share ideas for improvement. Leaders had set out clear governance structures, this included meetings for the different teams, for example, clinical meetings, Gold Standard Framework (GSF) meetings every 10 weeks, quarterly Clinical Governance meetings, monthly partners' meetings, monthly nursing team meetings and twice weekly reception meetings. There were leads for clinical and non-clinical areas. Leads took responsibility for ensuring that risk and performance data was accurate and actions were taken when concerns were identified or if processes needed improving

Leaders had oversight of risk and performance and took appropriate action to improve services further. Processes enabled data or notifications to be submitted to external organisations. Information was stored safely and used effectively to monitor and improve the quality of care. 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. However, we found some gaps in these processes. We discussed this with leaders during the assessment who offered immediate reassurances around their processes. They also told us they would be reviewing these processes further. We found other areas where governance arrangements were not fully effective. We found that GP assistants received comprehensive training and ongoing feedback and support from clinical staff; however, there was no formal monitoring of their documentation in patients’ records. The practice took action to respond to our immediate concerns during the assessment and told us they would review their processes further. During our assessment we did not identify any concerns with coding of records. However, leaders told us formal audits were no longer carried out. Non-clinical staff received comprehensive training on how to code patient records when reviewing external correspondence and initially leaders had carried out audits to monitor this. More recently, clinical staff provided immediate feedback to non-clinical staff if errors were identified. We found that this process was not comprehensive. It would not alert leaders to continued concerns with a particular staff member or a particular process nor did it evidence that clinical staff were alerting non-clinical staff in every instance if errors were identified. Generally, policies were reviewed and updated. However, information in the Mandatory Training List and the training log was different and the Complaints policy did not provide staff with sufficient guidance.

Patient feedback was positive about the practice working with other services. The patient participation group (PPG) representatives we spoke with were positive about leaders and that they worked with them to improve services.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Leaders shared learning following incidents and complaints with the provider so that improvements could be shared with other OHP practices. Staff worked with the primary care network (PCN) to deliver services to a wider population of patients. Staff worked with care home staff to deliver patient centred care. Leaders shared examples with us of where they had piloted and implemented systems and processes to improve the efficiency and effectiveness of the service and then shared this learning and development with other practices. Staff told us about a new initiative starting in October 2024, called a Community Appointment Day, where the practice was working in collaboration with local hospital trusts and voluntary third sector support services to provide holistic treatment and to provide support to patients on waiting lists for physiotherapy and other musculoskeletal services (MSK). It involved inviting patients on the hospital waiting lists to a central location in the community, for an opportunity to connect with a variety of clinical and voluntary sector support services. The outcome would be to reduce the waiting list size and waiting times for patients who remained on the hospital list. The focus was on preventative care and overall well-being, using a “What Matters To You” approach. If the day was successful it would be rolled out to other locations.

Feedback from partners was positive about the service. Staff listened and worked in collaboration with external organisations to meet their patients’ needs. Feedback from the ICB was positive about the service. We saw positive feedback from a company that the practice had been working with since 2016 to improve and innovate digital solutions that would improve patient access and experience in GP practices.

Leaders had implemented effective systems that allowed staff to communicate and collaborate with external partners. Staff and leaders engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the service. They used these networks to identify new or innovative ideas that could lead to better outcomes for people. In collaboration with a paediatric consultant and nurse from a local children’s hospital, the practice set up the south locality paediatric asthma service. This commenced in November 2023 and was available to patients that were registered with this practice as well as other local practices. The lead GP for this service held meetings with the consultant paediatrician and asthma nurse for complex/high risk patients. From evidence we viewed we saw this service had led to improvements in paediatric asthma care. For example, 91% of those children seen by the respiratory nurse clinic had no exacerbations since their date of attendance to April 2024. No child had suffered an exacerbation requiring A&E attendance or admission. The practice worked with a local organisation to provide a drop-in service at the practice for vulnerable families for them to access GP services and support for social issues. The practice shared an example which demonstrated how they had worked in partnership with this organisation to support the family with social issues and keep the adults and children safe from harm.

Leaders told us they supported improvement and were often the first adopters of digital services/solutions. Examples included solutions to improve patient experience, access and the registration process. Wherever possible they involved themselves in research and pilots to support clinical research and development. Leaders encouraged staff to report learning events so that learning could be shared with others in the practice and externally. At the time of the assessment, the practice were involved in testing an online system that would help triage correspondence and would support improved access to secondary care services. Leaders shared other examples where they had worked with secondary care services to improve services for patients which had then been rolled out to other GP practices. Staff told us about new initiatives starting in October 2024 where the practice was working in collaboration with local hospital trusts and voluntary third sector support services to provide holistic treatment to patients on waiting lists for physiotherapy and other musculoskeletal services (MSK).

Leaders had developed effective processes to learn from incidents and complaints. There were different ways for people to provide feedback, to drive further improvements. Leaders worked with staff, patients, the provider and external partners to drive improvement for their practice populations but also for the wider population. The practice was a training practice for medical students, trainee GPs and pre-registration pharmacists. Staff collected feedback from trainees, to monitor and improve further. Feedback we viewed was extremely positive about staff. Staff were supported to review performance and develop further. The practice had developed their appointment system as a result of trial and error as well as following patient and staff feedback. We saw that patient feedback was consistently positive about access and appointments. GP leads at the practice formed part of the provider’s cancer, governance and safeguarding committees. This meant they could learn from other practices as well as share good practice and help to develop new pathways that would support a wider patient population. We saw that in-house training sessions covered a wide range of topics including how to improve access and experience for vulnerable groups and staff wellbeing. The practice worked with local services to improve outcomes for their patients for example, the drop-in service at the practice for vulnerable families for them to access their services as well as access support for social issues and the south locality paediatric asthma services in conjunction with a specialist paediatric consultant and nurse. The practice took part in research and collaborated with the NIHCR (National Institute of Health and Care Research). They had been the host practice for a senior clinical research nurse since 2021. This involvement helped the practice stay at the forefront of medical advancements, enhancing the care and outcomes for their patients.