Headstone Lane 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

At our last assessment, we rated this key question as good. At this assessment, the rating has remained good. There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. Information was used effectively to monitor and improve the quality of care. Leaders implemented quality frameworks to improve equity in experience and outcomes for people using services and tackle known inequalities.

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.

Staff reported there was an open and honest culture within the practice, and they felt able to raise concerns without fear of retribution. When patients were affected by things that went wrong, they were given an apology and informed of any resulting action. There was an emphasis on the safety and well-being of staff. Staff reported that leaders were visible and approachable.

The practice had a clear vision and credible strategy to provide high quality sustainable care. The practice had a culture which drove high quality sustainable care. Leaders demonstrated that they understood the challenges to quality and sustainability and effective systems were in place to monitor progress with action plans.

Staff told us there was compassionate, inclusive and effective leadership at all levels. Staff told us leaders listened to their feedback, and they felt supported in raising concerns.

There was clear oversight and leadership from the partners within the practice and the management team. Staff had clear roles and responsibilities and were flexible in these roles in order to meet the needs of patients.

Staff told us there was an open and honest culture within the practice, and they felt able to raise concerns with the management team and leaders. They told us they had access to a Freedom to Speak Up Guardian, they knew who to contact and would, should they wish to raise any concerns.

There were clear processes in place for staff to speak up. Information was shared at induction and updates were given during meetings and minutes were available to staff. The practice provided information for anyone who wished to access a Freedom to Speak Up Guardian.

Staff told us they felt supported by the practice leaders and their peers. Staff gave examples of support they had been given by the practice, for example reasonable adjustments and flexible working.

There were systems and processes in place to ensure there were clear responsibilities, roles and accountability structures to support good governance and management. The systems provided an emphasis on the safety and well-being of staff.

Staff told us there were clear responsibilities, roles and systems of accountability to support good governance and management. They told us they were clear about their roles and responsibilities and who to contact should they need advice or want to discuss any concerns. The practice had an overall organisational chart which detailed practice governance arrangements. Staff were aware of those with lead roles, such as safeguarding, governance and performance. There were comprehensive assurance systems which were regularly reviewed and improved.

There were comprehensive assurance systems which were regularly reviewed and improved. This included those for managing risks for patients and staff such as fire safety and learning from safety alerts and significant events. There were clear action plans in place to ensure risks identified were mitigated, actions completed and monitored to ensure they were sustained. The process for using clinical audits had a positive impact on quality, and there was evidence of an audit programme for continuous improvement. There was a process to support and manage staff when their performance was poor or variable. The practice used digital services securely and effectively and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management.

The practice has responded to patient comments and told us they used the information to improve any issues raised. We saw evidence of where the practice had proactively sought to inform and involve patients in service improvement activity. For example, through the active patient participation group.

Staff gave examples of engagement and joint working with other services, both for the benefit of patients and also to support staff in undertaking their roles.

We saw evidence of proactive partnership working with statutory and voluntary sector organisations.

The practice worked with stakeholders to build a shared view of challenges and of the needs of the population. The practice worked with a range of external partners, for example, other health and social care professionals, mental health services and housing to support patients with a range of needs.

There was a learning culture in the practice which staff and leaders actively participated in. Staff talked positively about their experiences of joining the practice, moving to new roles and the ongoing support and development they received.

There were systems and processes for learning, continuous improvement and innovation. We saw evidence of effective supervision, audit and training including support given to staff to develop in new or extended roles.