• Doctor
  • GP practice

The Dove Medical Practice

Overall: Good read more about inspection ratings

60 Dovedale Road, Birmingham, West Midlands, B23 5DD (0121) 289 5257

Provided and run by:
The Dove Medical Practice

Important: The provider of this service changed. See old profile

Report from 16 July 2024 assessment

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Well-led

Good

Updated 21 November 2024

The leadership team collaborated with the wider organisation to provide stability and ensure clear roles and responsibilities 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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Shared direction and culture

Score: 3

Staff reported there was an open and honest culture within the practice and they felt able to raise concerns without fear of retribution. 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 clear processes to manage any behaviour inconsistent with the vision and values. Staff reported that leaders were visible and approachable.

The practice had a clear vision and credible strategy to provide high quality sustainable care. The vision statement was ‘Provide all patients with the best quality and accessible care’. The practice had a culture which 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.

Capable, compassionate and inclusive leaders

Score: 3

Staff told us there was compassionate, inclusive and effective leadership at all levels. Staff told us leaders listened to their feedback and shared some examples where changes had been made as a result.

There was clear oversight and leadership from the management team. Staff had clear roles and responsibilities and were flexible in these roles in order to meet the needs of patients.

Freedom to speak up

Score: 3

Staff told us there was an open and honest culture within the practice and they felt able to raise concerns with the management team and leaders. They told us they had access to Freedom to Speak Up Guardians, they knew who to contact and would, should they wish to raise any concerns.

There were clear processes for staff to speak up. Information was shared at induction and updates were given during meetings and minutes were available to staff.

Workforce equality, diversity and inclusion

Score: 3

Staff told us they felt supported by the practice leaders and their peers. Staff gave examples of support they had been given by the practice, including opportunities for learning and development. Staff felt empowered and were confident that their concerns and ideas resulted in positive change to shape services creating a more equitable and inclusive organisation.

There were systems and processes to ensure there were clear responsibilities, roles and accountability structures to support the workforce, this included human resource support. The systems provided a strong emphasis on the safety and well-being of staff. Staff and leaders had undertaken equality and diversity training.

Governance, management and sustainability

Score: 3

Staff told us there were clear responsibilities, roles and systems of accountability to support good governance and management. They told us they were clear about their roles and responsibilities and who to contact should they need advice or want to discuss any concerns. The practice had an overall organisational chart. Staff were aware of those with lead roles, such as safeguarding.

The practice had a variety of policies and procedures to govern the practice. These were accessible for all staff on the practice internal computer system. Staff were clear about their roles and responsibilities. All staff had a job description. There was a Business Continuity plan to provide a framework under which the practice could be managed and continue to operate under exceptional and adverse circumstances. There was a Business Development plan which was regularly reviewed. There were comprehensive assurance systems which were regularly reviewed and improved. This included those for managing risks for patients and staff such as fire safety and learning from safety alerts and significant events. There were clear action plans in place to ensure risks identified were mitigated, actions completed and monitored to ensure they were sustained. Clinical audits were undertaken, both to support locality initiatives and practice oversight of performance and risk. There was a process to support and manage staff when their performance was poor or variable. The practice used digital services securely and effectively and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management. Staff used data to monitor and improve performance. We found the workflow of communication information, such as hospital letters and medical record summarising were up to date.

Partnerships and communities

Score: 3

The practice engaged and sought feedback from patients via surveys, complaints and compliments. There was a Patient Participation Group (PPG) and the member we spoke with was positive in their reflections of the practice and how they were engaged as a group. They spoke of efforts to actively encourage more people to join the group.

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

We received feedback from 5 partner organisations, who were complimentary about the practice’s efforts to engage and support them to enable collaborative working in delivering care and safe services to patients.

The practice was part of a Primary Care Network (PCN), and staff were able to demonstrate effective working relationships with the PCN, particularly the use of additional staff through the additional roles reimbursement scheme (ARRS) to improve access to care for patients. There were regular meetings with partner organisations, such as care homes and local leads for safeguarding to ensure safe and effective service delivery for vulnerable patients.

Learning, improvement and innovation

Score: 3

There was a learning culture in the practice which staff and leaders actively participated in. Staff talked positively about their experiences of joining the practice, moving to new roles and the ongoing support and development they received.

There were systems and processes for learning, continuous improvement and innovation. We saw evidence of effective supervision, appraisal and training including support given to staff to develop in new or extended roles. We saw that through the practice’s own assurance systems improvements to specific clinical records were identified and processes established quickly to address concerns.