Cavendish Health Centre

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• 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

At our last assessment, we rated this key question as good. At this assessment, the rating has remained the same.We looked for evidence that service leadership, management, and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open, fair culture. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.

There were clear responsibilities, roles, and systems of accountability to support good governance and management. Staff understood their roles and responsibilities.Leaders were visible, knowledgeable, and supportive, helping staff develop in their roles. Staff felt supported to give feedback and said they were treated equally, free from bullying or harassment.

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.

The service had a shared vision, strategy, and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We saw that policies were reviewed and updated regularly and staff had easy access to them. Leaders informed us they regularly communicated with outside bodies like the wider PCN, ICB, and GP Federation to ensure that the practice ran smoothly.

Staff were positive about the culture of the practice and told us they felt valued and supported by practice leaders. Leader and staff told us there was an open culture, and leaders were approachable. The practice offered flexible working arrangements where possible. The leaders explained they encouraged celebration and recognition of all religious needs and festivities and had incorporated a prayer room. Leaders introduced a Ramadan and Menopause policy to meet the needs of their staff. The practice had a business continuity plan and disaster recovery plan to allow them to operate under exceptional and adverse circumstances.

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 organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty. The leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area. Staff we spoke with were aware of those with lead roles in the practice. Staff told us they had access to training and development and leaders in the practice responded to any concerns raised. Staff also told us leaders modelled the values of the practice.

The practice promoted a positive culture where staff felt they could speak up and their voice would be heard. There was a whistle blowing policy in place and this was last reviewed in February 2025. There were clear processes in place for staff to speak up and the practice had an internal and external freedom to speak up guardian. The practice had established freedom to speak up arrangements with other practices in the primary care network. The service fostered a positive culture where people felt they could speak up and their voices would be heard. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to a positive effect.

Policies and procedures to promote diversity and equality were in place. Practice leaders encouraged teamwork and inclusivity and supported this through staff events. The service valued diversity in their workforce, they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff gave examples of support they or other staff had been given, for example, flexible working, arrangements for time for religious beliefs to be practiced and reasonable adjustments being made.For example, there was a prayer room. All staff had completed equality and diversity training. Staff had access to continual professional development, support, and mentorship. Leaders spoke about supporting staff to develop in areas of their interest. For example, the receptionist received training to assist with coding, and the healthcare assistant received additional training and support and, as a result, has been upskilled in her role.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals. The practice had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously. The service had clear responsibilities, roles, systems of accountability, and good governance. They used these to manage and deliver good quality, treatment, support, and sustainable care. The service had a clear vision and oversight.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The practice used the same patient records system as external agencies such as district nurses, and this allowed for better continuity of care. Staff had made adjustments to improve the coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those with complex needs.

The partners were involved in the local primary care network and one partner acted as educational and research lead at the federation. In addition, the partners are involved in the GP training. The service was involved in meetings with other healthcare providers in the local area to develop the way care was delivered.

The service focused on continuous learning, innovation, and improvement across the organisation and local system. Training events are held at the practice, which included for example ‘lunch and learn’ sessions with external speakers which had recently covered diabetes. The undertaking of staff surveys, and patient surveys encompassed a culture of learning. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people, for example a protocol is in place for broad spectrum antibiotic prescribing. They actively contribute to safe, effective practice and research. The practice is a GP training practice, for medical students, GP Registrars, pharmacists, paramedics and other professionals. One partner was also responsible for supervising independent prescribers and is the education lead for four primary care networks.