Primary Care 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 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 Inadequate. At this assessment, the rating has changed to Good.

The service was previously in breach of legal regulation in relation to:

• The provider had ineffective communication systems. We found no evidence to demonstrate that the outcomes of incidents had been shared with the practice team to mitigate future risk.
• We found clinical coding was not being monitored to ensure clinical records were accurate and provided the appropriate information.

At the last inspection we found the practice did not have a fully embedded governance system, there was a lack of leadership and oversight, there was no evidence that there were effective arrangements for identifying, managing and mitigating risks and there was no evidence of systems and processes for learning, continuous improvement and innovation.

At this assessment, we found that the provider had taken action to address areas of governance, management and accountability and there were now safe systems in place to manage performance to ensure staff had the skills and knowledge, so people had safe care and treatment.

We found that the leadership team had been strengthened with 3 new GP partners and a new practice manager and there was adequate oversight and systems in place to manage risk, issues and performance. The practice had designated roles for areas of accountability. There were succession plans in place, supported by a business plan and the practice had made significant improvements to ensure quality outcomes were fully sustained.

Leaders and staff shared a clear vision and culture in listening, learning, and mutual trust. Staff told us the leadership team were supportive, actively fostering staff development. Staff reported feeling empowered to provide feedback and described a workplace culture that promoted equality and was free from bullying or harassment. Roles and responsibilities were well understood across the team. A culture of continuous improvement was evident, with staff supported through time and resources to explore and implement new ideas.

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, engagement, and understanding challenges and the needs of people and their communities.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. At the time of the assessment, 3 GPs had joined the partnership in April 2024, supporting the provider’s capacity to meet future demand.

There was an open culture and clear learning within the practice. Regular meetings were held with staff and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care. Team members highlighted effective communication and stated that they felt included in decision making processes relating to the service.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

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 was approachable and responded to any concerns raised.

Leaders understood the challenges to quality and sustainability and had reviewed their business plans to ensure there was capable and effective leadership. The practice had the appropriate oversight and supervision to ensure staff were carrying out their roles effectively. There were plans in place for the development of staff as part of their succession planning.

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

There were regular meetings held with staff and there was a freedom to speak up guardian in place. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve. All staff had undertaken equality and diversity training.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue.

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.

There were policies and procedures in place for the safe recruitment of staff which had been reviewed further since our last inspection. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, one to ones, coaching and mentoring, clinical supervision and revalidation. There was an induction process in place for newly appointed staff and new staff told us that they were well supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available.

As part of the practice’s mandatory training, we saw evidence that all staff had completed equality and diversity 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.

At the last inspection, we found the practice was unable to demonstrate that there was clear oversight of governance arrangements to ensure risks to patients were considered, managed and mitigated appropriately. At this assessment we found improvements had been made, but required further strengthening to ensure all risks were mitigated. For example, the management of patients with long term conditions and medicines management.

We were told that there were regular management meetings to review sustainability and ensure there was enough staff in place. There were contingency plans and arrangements in place to recruit locum staff for the needs of the service.

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 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 understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders told us they worked with stakeholders and the local community. The practice was part of a PCN which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

At the last inspection there were no regular meetings being held with staff; however, this had been reviewed and there was evidence that regular meetings were held to share learning from incidents and complaints and discuss improvement plans. In addition, the practice held regular clinical meetings to collaborate effectively and make improvements in patients care and treatment.

A Patient Participation Group (PPG) was in place and meetings were held every 3 months. There were 8 active members. The practice had engaged with the PPG on areas of improvement in the last 12 months such as Friends and Family Test (FFT), patient survey feedback, complaints and access. Feedback from the PPG highlighted the dramatic changes that had happened in the past 9 months at the practice with significant improvements seen. These included the new phone system, the increase in clinical partners and how the practice was engaging with external groups to provide information and presentations on healthy eating and pharmacy services.

The practice had implemented a newsletter to provide information on local services, information about the practice and community events. For example, there was information on activities for children, young people and families in the locality.

The leadership team were aware there had been increases in demand and they were working with the primary care network and stakeholders to ensure that resources were planned with continued collaboration and partnership working to meet the needs of the service.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

At the last inspection we found no evidence to demonstrate learning from incidents and complaints was shared with staff to mitigate future risks. We also found no improvements had been implemented following patient feedback. At this assessment, the practice showed a strong commitment to continuous learning and improvement, and learning was shared with all staff on a regular basis. Regular clinical meetings were held to review patient needs and discuss best practice.

Feedback from staff and people who used the services of the practice, highlighted the improvements that had been implemented over the past 12 months. This included increased clinical team, new telephone system and updated practice website. An inhouse phlebotomist was now available for patients who could not attend local community services.

We also found the practice had implemented a programme of induction and training for all newly appointed staff. This was regularly reviewed by the leadership team to ensure training was monitored and kept up to date.

Systems were in place to assess the quality of the service and monitor patient outcomes. Where areas for improvement were identified, appropriate actions were taken to enhance service delivery and prevent recurrence. This was demonstrated following the remote clinical searches, where we identified concerns in the management of people with long term conditions and the management of medicines. Following our feedback to the clinical team, they commenced an immediate review of the clinical searches, and we were provided with evidence to demonstrate that all the people identified had been contacted to organise the appropriate reviews. The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.