Wetherby Health Centre

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• 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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as good.

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.

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 and managers had spent the previous 2 years since forming the service striving to build a shared direction and ethos with staff. All staff we spoke with were very clear that they wanted to provide excellent, sustainable, accessible local care to patients, and appreciated how important their service was to the community. Staff also mentioned that the culture of the service was supportive, and that they were encouraged to develop within their chosen career route, and managers told us that they wanted to empower to influence the practice moving forward.

We saw that the provider recognised the importance of staff wellbeing and maintaining a healthy work life balance and made adjustments when required to achieve this.

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.

When we spoke with staff, or reviewed responses to Care Quality Commission (CQC) questionnaires which had been sent to staff as part of our assessment, they told us that they felt supported by leaders and managers in the practice. In particular, staff felt that leaders and managers had offered training and development opportunities to them, and that they felt confident in raising concerns with them.

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.

We found that the provider fostered a positive culture where staff and patients felt they could speak up, and their voice would be heard.

The provider had put into place freedom to speak up arrangements, and staff we spoke with fully understood who to contact if they had a concern that they needed to raise. Freedom to speak up and other related topics such as grievance and whistleblowing processes were accessible to staff on the practice’s shared information access platform. Managers told us that they had an open-door approach which allowed staff to raise concerns with them directly, and this was corroborated by feedback we received from staff who told us that they were empowered to raise concerns and felt confident if they needed to do so. Staff told us that they felt that leaders and managers were approachable, and friendly, and they felt any issues they raised would be listened to and investigated fully. Human resources consultancy support was available to support the speaking up process.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. We saw that there were key policies and procedures in place to promote diversity and equality were in place, which included a bullying and harassment policy, a stress at work policy, and a zero-tolerance policy for dealing with unreasonable, violent and abusive patients.

When we reviewed training records, we saw that staff had completed mandatory equalities and inclusion training. The provider had a strong focus on equality of opportunity, and we saw that many staff had received additional training and career development opportunities. As part of the appraisal process career development was actively discussed.

The provider had undertaken a staff survey in late 2024 which covered staff at the practice and Bramham Medical Centre. This showed that staff were generally positive about many of the aspects of their work life including teamwork and the supportive culture of the practice. However, it also raised other issues which staff felt could be improved upon including communication, working practices and flexibilities, and workload pressures. The provider has used this feedback to introduce improvements, and had recognised the importance of staff involvement in the co-design of solutions and in discussing emerging issues. With this latter point in mind, at the time of the assessment the provider was forming a staff participation group to enable staff to have greater input into the development of the service.

The provider had in place clear staff responsibilities and roles, systems of accountability and evidence of good governance which covered both GP practices operated by the provider. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews, and to share information with them. In particular, staff told us that they valued their daily huddles when operational issues could be raised, and advice sought.

The provider had governance processes appropriate for the service, these included core policies, standard operating procedures and a business plan. The business plan outlined the provider’s approach to key drivers for the organisation, and included patient access, staffing and sustainability, building clinical excellence and financial stability. Staff could access all necessary policies and procedures on their shared information platform. A check on a selection of policies and procedures showed these to be all in date and to have been reviewed regularly. Partners meetings were held on a quarterly basis, and team meetings were held monthly, with new and emerging operational issues being discussed at daily huddles.

Senior staff had been appointed to lead areas of delivery, this included prescribing, and handling confidential health and care information.

The practice had a business continuity plan with clear guidance for systemic failures and emergencies which put the operation of the practice at risk. This was detailed and covered mitigating and control factors, and outlined prepared recovery actions.

Leaders and managers had effectively dealt with the establishment of the new practice since taking over the contract for the service in July 2023, this included recruitment and the introduction of new working practices. They were aware of ongoing challenges such as the retention of staff, and had plans in place to manage these.

We saw that staff treated patient confidentiality and information security seriously, and staff were aware of information governance best practice, and had completed mandatory information security training.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders and managers collaborated with other practices in their primary care network (PCN) to deliver services such as extended access appointments. They also worked closely with PCN staff who supported their patients. This included paramedics and pharmacy team members. Feedback from a member of the PCN team supporting the practice endorsed the close working across teams and the support they received from the practice.

The practice held multidisciplinary meetings to discuss and improve outcomes for patients with complex needs. This included regular meetings including those with safeguarding, and palliative care colleagues.

We saw that measures were in place to engage with the public and patients. Patient feedback and practice responses were displayed on a comments board in the main premises reception area, and patient views were sought via the NHS Friends and Family Test and a recent patient access survey. The practice had a patient participation group (PPG), but recognised that activity with the group was limited, and saw this as a future priority for action.

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.

The practice had a programme of quality improvement activities which included clinical and non-clinical audits, clinical supervision, and regular searches of the clinical system to ensure compliance with best practice principles. This approach to improvement was bolstered by the implementation of learning from significant events, near misses, complaints, and feedback from patient and staff surveys.

The provider had undertaken work to tackle known and emerging issues. For example, it had taken part in work to reduce opioid prescribing and support patients to reduce dependence.

The provider placed a strong emphasis on learning and development. For example, we saw that staff had opportunities to gain more advanced levels of training, there were processes in place to support personal and professional career development. We saw that the provider held regular meetings with staff where learning including audits, events and complaints could be discussed. On a more informal basis staff were able to discuss cases of interest at the daily huddles held in the practice. As an example, of improvement driven change following complaints and feedback from patients, the provider had installed a new telephony system with improved functionality including patient call-back, real-time awareness of call queues and pressures, and the ability to better inform management planning regarding patient access and staffing.

Working with their primary care network, we saw that the practice had developed some specific services such as care home, and home visiting support. It also supported work to establish a twice-weekly Leg Club, a wound care clinic located in Wetherby. The Leg Club provided high-quality wound management in a collaborative, community-based setting that also supported patients’ social and emotional wellbeing.

The provider recognised that geographical isolation and deprivation was a key issue. In response to this the practice worked with others to deliver or host services within their locality for the benefit of their patients. Services included hosting audiology and ultrasound services, and supporting patients with heart failure through joint working with a cardiologist.