Lees 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 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.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

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. This was based on transparency, equity, equality and human rights, diversity and inclusion and. The practice was working hard with other practices, the commissioners and the PPG to find ways to engage with and understand the challenges and the needs of the local communities.

Leaders led staff in developing the vision and strategy for the practice, this was continually being reviewed. The message was also reiterated during discussions and meetings. Planned staff development including employing new members, the development of new roles and job description reviews, were ongoing.

Staff described a fair and open working culture. They told us they were trained in non-judgemental signposting and described the culture as being respectful, open and non-discriminatory.

The service had inclusive clinical and administration leaders. In the main staff 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.

In response to patient feedback leaders identified the need for a specialist role responsible for dealing with problems and trouble shoot issues as they arose. This work was being monitored to identify where changes can be made to improve patient satisfaction.

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.

The service fostered a positive culture where staff felt they could speak up and their voice would be heard.

Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. We noted a diverse range of staff employed at the practice.

Policies and procedures to promote diversity and equality were in place. Leaders confirmed that staff worked in line with anti-discrimination best practice and had completed specialist anti-discriminatory and anti-bias training.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. Some roles and responsibilities had been newly introduced and so at an early implementation stage.

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 and performance reviews. The provider was establishing 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 understood their duty to collaborate and work in partnerships, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access.

Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

Leaders need to do more however, to understand the communication needs of the local community so that relationships and patient satisfaction is improved.

The service should investigate creative ways of developing a positive relationship with their patients.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They actively contribute to safe, effective practice and research.

The practice had several quality improvement plans in place to help drive improvements in services. They had produced a risk assessment which helped to prioritise the importance of each topic.

The main priorities included improving the appointment systems; ensuring safe prescribing; safe recruitment and patient satisfaction.

Feedback from commissioners and other data sources indicated that learning and improvement had taken place. Commissioners did not have any immediate concerns about the management of the practice.

Feedback indicates that more time is needed for changes to make a difference to patients.