Yew Tree 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 assessed all quality statements from this key question. The rating given is Good. Leadership, management and governance ensured high-quality, person-centred care and treatment was provided. We found the provider had clear and effective governance processes, which supported the safe delivery of care. Leaders clearly demonstrated capability, compassion and inclusiveness. Workforce equality was a priority for the leadership team. Staff understood their roles and responsibilities and those of other members of the team and lines of accountability were clear. Staff felt well supported in their role. Staff were provided with information about speaking up. They told us they felt confident to raise issues and that if they did these would be listened to and acted upon. The provider supported learning and innovation and promoted an open, learning culture. Leaders demonstrated that they understood the challenges to quality and sustainability. Information was used effectively to monitor and improve the quality of care and treatment provided. However, there were areas in records and data management systems that were not well maintained and we discussed this during the assessment process. The practice was responsive to our feedback.

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.

The service had a shared vision, strategy and culture which was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively. Staff spoke of a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. All staff we spoke to felt positive about working at the practice and feedback from staff questionnaires was consistently positive about working at the practice. They described good teamwork and a service that was clear on its function to work in the interests of patients and providing the best patient experience they could. Regular meetings were held for clinical and non-clinical staff. Members of the team told us that communication was effective but could be improved to ensure that all team members received the right information at the right time in the right way, rather than by accident.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

Leaders were visible and had the skills, knowledge, experience and credibility to lead effectively. They monitored and acted upon data about outcomes for patients and made improvements when required. Feedback from people who used the service was very positive with regards to the capability and compassion of the staff and leadership team.

We were aware of concerns from staff previously working at the practice where they felt they had not been listened to. However, this culture was not apparent from our assessment and all concerns that had been previously raised had been addressed. There was a Freedom to Speak up Guardian within the Primary Care Network (PCN) and all staff said they were aware who that person was. Staff knew how to raise issues, said they felt confident to do so and felt their concerns would be acted upon.

Leaders said they encouraged staff to raise concerns and promoted the value of doing so.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by supporting equality and diversity for people who worked for them.

Reasonable adjustments were made to support staff to carry out their roles. Staff with caring responsibilities were actively supported with a flexible approach and changes to schedules to accommodate their needs. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. The practice had an equality, diversity, and inclusion policy.

There were clear and effective arrangements for governance, management and accountability.The provider used data to monitor and improve performance. All staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. A regular suite of searches of the clinal record system were being run to identify patient needs and ensure these were being met and our review of clinical records showed that this was effective. Staff knew where to access all required policies and procedures and understood the importance of patient confidentiality and information security. There were arrangements for identifying, managing, and mitigating risks and a major incident plan was in place. The provider had established governance processes that were appropriate for the service. However, with regards the recruitment of nonclinical staff the practice could not demonstrate this was safely undertaken because of incomplete documented evidence and poor record keeping. We were assured during the assessment process that no member of staff had been unsafely employed, and the provider had an action to address the failings. In addition, because of administration difficulties, the service was not registered appropriately. This was also being addressed. The lead partner had been absent from work for an agreed extended period of time but the relevant notifications had not been made to CQC. In addition, there was no documented process in place to manage how the practice would work during their absence and this had caused instability. We were told they had continued to do some work during their period of agreed absence.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. They worked collaboratively and in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop effective services. They had a Patient Participation Group (PPG) that was run by the PCN.

There was a focus on continuous learning and improvement across the service. There were regular clinical meetings to discuss patient needs and best practice. Systems for assessing the quality of the service and outcomes for patients were in place. There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence. The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.

Leaders told us they maintained strong external relationships that supported improvement and innovation. In November 2024 the practice conducted “The Blood Pressure Project” to enhance the management of patients with hypertension. This is an ongoing initiative to reduce morbidity and mortality in the medium and long term.The practice has also undertaken significant efforts to reduce GP workload, particularly in the areas of document management and medicines management. By doing this the practice has freed up an average of 1.5 hours of GP time per day.The provider employed a GP trainer and aspired to becoming a training practice. The clinical pharmacist aspired for the practice to be involved in research programmes.

Looking forward the practice aim to further enhance their services by introducing a dermatology interface between primary and secondary care.