Halcyon 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

We assessed all 7 quality statements under the well-led key question. We looked for evidence that the practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first inspection for this practice since its registration with CQC. This key question has been rated as good.

We found there was an inclusive and positive culture of continuous learning and improvement shared by all staff. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred, sustainable and reduced inequalities. Leaders understood their local population and endeavoured to provide inclusive, flexible and accessible services. Leaders embodied the values they had set out for the practice and staff had embraced their strategy and vision for the future. There was an organised, effective and mostly comprehensive system of governance that managed risks and kept staff and people safe; however, we found some areas lacked effective managerial oversight. Leaders had a clear business plan and gathered feedback and information about risks, performance and outcomes which they used effectively to make decisions about future developments.

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. The practice had developed a clear mission statement and values, all staff were aware of this and we saw they strove to live these values in their day-to-day work. Following the appointment of a new leadership team and a review of the culture the partners had instilled a clear vision and team dynamics at the practice. All staff mentioned excellent patient care, safety and learning as priorities. Staff all talked about an open, transparent, no blame culture and positive support from management. We saw that multiple trainees had returned to the practice once qualified. Several staff told us it was the best practice for which they had worked.

The practice 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. The leadership team worked well together and modelled the behaviours and culture they expected of the staff. Staff respected and valued the leadership team and felt they were open and transparent.

The 3 partners in the partnership were experienced and formed a stable team. They had a clear vision and business plan for how the practice would grow and progress. They were always striving for excellence. They had a thorough understanding of the nature and challenges of primary care. All partners carried out clinics at least weekly and worked as duty doctors which gave them understanding and oversight of the daily challenges staff faced. The practice was a teaching practice with 5 GP trainers and trained various medical and nursing students at all levels. The partners were passionate about providing excellent training and developing the next generation of clinicians. GP trainees we spoke to spoke highly of the quality of training they received.

Several staff spoke about compassionate management when they have had personal issues that have affected them at work. The partners demonstrated that they understood the importance and impact of a positive culture and were sensitive to the difficulties of changing a workplace culture. They had found proactive ways to address it by using an independent company to do a comprehensive culture review shortly after taking over the practice. They had carried out a staff survey to enable oversight of staff feelings / culture over time and had acted on feedback by providing staff with a common room. 

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. All staff understood the concept of freedom to speak up, the policy and knew who the guardian was for the practice. All said they would be confident to speak up and would expect action. We saw action was taken to make change and implement learning after complaints or learning events. All staff had freedom to speak up training. Staff we spoke did not have a named guardian they would go to outside the practice but felt they would easily be able to find a suitable contact at the ICB if they needed it.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. There were robust, fair and transparent recruitment policies and procedures. A random sample of staff files we reviewed showed staff were all suitably qualified, with specific training for specialist or extended roles. All staff had DBS checks to the appropriate level. Staff were provided with protected learning time and had completed all required mandatory training. Staff were supported to develop themselves with access to continuing professional development (CPD) opportunities and paid study leave. Staff were encouraged to progress their careers. Staff said they felt valued and were nurtured to become the best clinicians they could be. The practice had several non-medical / independent prescribers, a specialist gynaecology nurse and a specialist diabetes nurse. GP trainees were encouraged to undertake audits for the benefit of their training and the practice. Salaried GPs also spoke of opportunities to progress their skills which were discussed at appraisals.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Mostly the leadership team had oversight of health and safety risks however, we found this to be lacking with regard to the consistent provision of hot water at the practice. Although deficiencies in water temperatures had been identified in a monthly audit there was no effective system to escalate and act on this data. Leaders did not appear to be aware that audits showed a consistent problem. They were overly reliant on a satisfactory annual testing regime and had not implemented effective control measures to identify issues between these tests; as shown by the fact that the water temperatures at all taps were tested and passed during the Legionella risk assessment on 16/1/25 but by the time we visited on 7/2/25 hot water was not available in some clinic rooms. The leadership team did not demonstrate that they fully appreciated the scope and importance of these issues and could not provide evidence of a clear, systematic and proactive approach to managing it.

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. Appropriate governance policies and procedures were in place and all staff could access them. 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. The daily midday 10-minute huddle with a set agenda was a useful improvement that allowed immediate information sharing, gave a forum for staff to seek advice and support and brought all staff together every day. Staff had protected time for this meeting and it was well-attended. Staff took confidentiality and information security seriously especially when using the staff ‘WhatsApp’ group.

The practice had a ‘green’ agenda for example encouraging staff to use public transport to support environmental sustainability. The practice had worked hard to move all of their asthma patients onto dry powder inhalers to reduce the use of aerosols in metered dose inhalers, however, this initiative had to be stopped due to a change in the local formulary. Overall, there was an awareness and commitment to environmental sustainability and the practice continued to reduce carbon waste by being as paper light as possible.

The practice clearly understood and carried out their duty to collaborate and work in partnership with others to provide seamless services for people. They always shared information and learning with partners and collaborated for improvement. The practice had good working relationships with the wider MDT across their patch, the ICB and PCN. We saw evidence of collaboration with the ICB through several medicines’ audits. They held regular meetings with district nurses, health visitors, social workers and hospice staff. They had a close working relationship with their nearest pharmacy (Boots) and a pharmacist from Boots attended the practice clinical meeting fortnightly. They had outreach links with 3 local universities, LGBT+ groups, the health exchange (a health centre for homeless people), a community centre for the local Chinese population and asylum seeker venues.

Staff spoke about close links with the staff at the laboratory that processed their cytology samples, whereby they had asked the laboratory to provide them with an annual quality assurance audit to corroborate their own in-house audit. When new in post the practice IPC lead had invited the ICB IPC lead to do a walk round and help initiate their IPC audit to ensure it met current guidelines. There was an active PPG program of education sessions, often provided by external speakers which PPG members reported were very informative and were generally well attended. As a teaching practice staff maintained close links with the local deanery and university staff as they supported undergraduate medical and nursing students as well as business apprentices.

The practice 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. The practice had a quality improvement plan in place to help drive improvements in services. Staff and leaders ensured that people using the practice, their families and carers had opportunities to provide feedback on care received, and used this to help drive improvements. The staff had carried out an extensive range of audits over the previous 12 months, many of which were completed full audit cycles and resulted in improvements in care for people. For example, the practice had carried out an audit to improve the care of asylum seekers. Staff reviewed coding, emergency department attendances, mental health diagnoses and use of the social prescriber. Following the audit, the practice improved their process so that all new asylum seekers who registered were booked an appointment to see an HCA within 1 week to carry out a thorough assessment of their needs and facilitate rapid access to support. Other areas audited included safeguarding, 2 week wait referrals and ante-natal and post-natal care.

Staff CPD was facilitated by provision of weekly consultant led tutorials, recent examples included cardiology and upper gastrointestinal surgery. Leaders had a proactive business plan designed to address the challenges facing primary care in general and their specific practice populations including implementing advanced telemedicine, expanding and upgrading their premises, introducing targeted clinics for mental, women’s and travel health and increasing capacity through recruitment.