Berrycroft Community Health 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 the quality statements in the well led key question. We found there were effective governance processes in place. The service enabled team working and there were dedicated clinical and non-clinical staff working at the service. Some staff reported that communication and decision making from executive leadership was not always inclusive or effective.

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.

We received staff feedback from a variety of sources. This feedback demonstrated that staff did not always feel involved in the strategy and decision making of senior leaders. They felt decisions were often made in which they were not consulted and were sometimes communicated poorly.

There were processes to plan for the changing demands of the local population. The practice had formed through a merger to consolidate and improve services and facilitate moving into purpose built premises. The leadership team monitored progress and performance in terms of national benchmarking on clinical outcomes and patients feedback.

Staff feedback demonstrated that senior leaders were not always inclusive and collaborative in their approach to strategic direction and decision making. The staff working at the practice informed us they believed they worked collaboratively and they were well supported by compassionate colleagues in their teams.

Training on equality and diversity was provided to staff. There were meetings to share information and ensure staff had an opportunity to share concerns with their line managers and colleagues.

Staff were aware of the significant event processes and attended meetings where they received feedback. Staff feedback indicated they were not always aware of the freedom to speak up process or named person.

Staff were provided with the services freedom to speak up information via a newsletter in January 2024 and evidence showed they were sent the provider’s whistleblowing policy and asked to acknowledge reading the policy.

Staff informed us they had access to training in in equality diversity and human rights. They told us there were staff meetings to enable participation and information sharing related to their roles.

There was training for staff in equality diversity and human rights and these requirements were included in policies.

Staff told us about the governance processes used to monitor the care provided, the quality of the service and also safety of the service. They informed us about processes to monitor long term conditions management, medicine reviews, infection control and medicine management including emergency medicines and equipment. Staff understood who was responsible for areas of governance and their appointed leads who oversaw medicines management, infection control and the maintenance of premises and equipment.

There were governance processes for ensuring equipment was calibrated and serviced and that risks associated with the premises were governed. Clinical care was monitored through data and patient outcomes. There was clinical audit based on areas for potential quality improvement but this was limited to one repeated audit. There were effective governance processes for overseeing patients’ prescribing and optimising the use of specific medicines. The practice using patient feedback to identify quality improvement in delivering improved services and governing their access to appointments.

Patients received information from the provider regarding improvements to services made as a result of patient feedback. This included changes to the appointment system and clinical triage.

Staff and leaders informed us of how they worked within locality with other health providers such as district nurses, social care providers and GP out of hours services to develop their services and deliver patient care.

Local commissioners and care homes confirmed the practice worked with them collaboratively.

The practice had processes to manage peoples care in coordination with NHS 111, care homes GP out of hours and other external services. There was engagement and two way communication with the practice’s patient participation group.

Clinical staff informed us they worked on audit and quality improvement work including the processes to manage long term conditions. GPs and the nursing team felt involved in the developments around this area of clinical care and had actively worked on assisting the development of virtual long term condition reviews alongside support staff.

There were processes for developing improvements in practice. These included altering the clinical triage process for patients to enhance efficiency and accuracy of clinical triage to enable patients to receive improved initial assessments of their needs. There had been consolidation of medicine reviews and long term condition reviews to enable patients to have a more holistic assessments of their multiple healthcare needs at one time. Increasing the diversity within the clinical team had enabled a broader set of clinical appointments to meet patients needs. There was no conclusive evidence that the changes made to improve patient access to services had resulted in improved patient experience.