Bay Medical Group

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 quality statements in this key question. At our last inspection the practice was rated requires improvement in well-led. This was because governance processes were not consistently effective, staffing pressures were impacting on staff wellbeing, not all staff felt supported or that leaders were visible and approachable, and the provider had failed to submit statutory notifications to CQC. During this assessment, we found that some improvements had been made, but the key question remains requires improvement overall. We identified a breach of the legal regulations in relation to good governance. Some policies needed updating, did not contain enough detail to guide staff, and were not being followed. Audits had not highlighted issues such as around infection prevention and control. Complaints and significant events were not managed consistently. Staff were not included in discussions around learning unless they had been directly involved in incidents. No-one had overall oversight of the practice.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders felt there was a clear vision for the future of the practice. Leaders and staff could demonstrate positive changes the practice had made. However, some of the changes, such as to the complaints process, were not fully effective.

The provider had developed a mission statement, vision and values for their practice. These were shared with staff. There was a business plan that was updated annually and monitored throughout the year. There was also an operational plan for each site, monitored by the site managers. However, the actions required in the operational plans had not always been carried out effectively. For example, they had not highlighted out of date equipment.

Leaders had the experience, capacity, capability and integrity to ensure that the practices’ vision could be delivered, but risks were not always well managed. Leaders were not aware of issues outside their direct line of responsibility. There was a Partnership Board, Executive Team and an Executive Practice Manager, as well as an operational management team, and a manager on each site. Although there were different meetings for different groups of personnel, no-one had overall oversight of how the practice was run.

A recent staff survey had been carried out and results were mixed. Some staff said management was not consistent, and they were overworked and frustrated. However, other staff said they felt supported, listened to and able to raise any concerns with leaders. This feedback was reflected in our interviews with staff. A plan was in place to act on the results and a repeat of the survey was planned.

Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns. Staff were confident that their voices would be heard. Staff knew who their freedom to speak up guardian was and how to contact them.

The practice had a whistleblowing policy that included details on the procedure to raise concerns and the contact details for the freedom to speak up guardian in their area.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. Regular awareness sessions were given to achieve a fair culture for all staff.

The practice had an equality and diversity policy, and staff had completed equality and diversity training. The practice had an inclusion group. This was in its early stages, with the group discussing its remit. The practice had been awarded the Pride in Practice Bronze Award for excellence in lesbian, gay, bisexual and trans healthcare. It was looking to progress to being awarded the silver or gold award.

Staff told us they were clear on their individual roles and responsibilities. However, they told us the work atmosphere was very busy and stressful, and there was a high workload. We were told that small changes were difficult to implement due to bureaucracy in the practice, and this could mean the improvements did not take place.

Governance processes were not always effective. Some policies needed to be updated, and some did not contain enough detail to guide staff. We also saw some policies were not being followed. Staff were not all given the opportunity to attend meetings.

People from the patient participation group told us they were involved in developing the practice and suggesting improvements.

Staff and leaders engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the service, such as working with local community groups. They used these networks to identify new or innovative ideas that could lead to better outcomes for people.

Partners had no specific feedback on this area.

The practice had regular multi-disciplinary team meetings with the wider health team, so people had the benefit of their health being managed holistically.

Leaders explained how they piloted and assessed different roles, including a paediatric dietician, in the practice with a view to improving efficiency and patient care. Most staff said they felt supported by managers, but some told us some managers were not approachable and they did not feel supported. Some staff said they were not included in meetings where learning was discussed.

The practice had reviewed the system for managing significant events and complaints. Learning from these was not managed consistently, and some concerns were not discussed with relevant leaders and staff for several months. There was not a system in place to share learning with staff who had not been directly involved in incidents. The practice was a Unified Learning Environment (ULE), providing a setting for all learners to apply their skills and knowledge and achieve their competencies. Learning included student nurses, medical students, physician associates, trainee GPs and others. A team closely monitored all learners, and each had an individual plan. An external review of the learning environment had been carried out following our October 2023 inspection, and feedback was positive with no concerns raised. The team also managed clinical supervision. This was well-managed with all supervision meetings documented. There was a programme of quality improvement audits that was monitored. The practice had an established patient participation group. Feedback was positive. The group felt involved and felt listened to. They met regularly and were able to submit ideas.