Gill Medical Practice

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 in December 2015, we rated this key question as good.

At this assessment in August 2026, the rating remains the same because the practice was proactive in its leadership of the service and we did not find any issues with governance, management and sustainability including learning and innovation for improvement of service delivery.

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 service had 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 ensured the mission statement and strategy of providing high-quality care that showed improvement for patients in a person-centred way was understood by all the staff. Each practice meeting was used an opportunity to remind staff of the values and vision. The practice was aware of the challenges of the local community and working with partner agencies to address them to improve the patient health and experience. For example, the practice engaged with the child safeguarding team to verify the internal safeguarding registers are aligned with the community team’s records. This helped other practices to remain fully aware of the patients who needed additional safeguarding oversight. This was shared with several practices within the primary care network (PCN). This was recognised by the clinical director of the local PCN. The local safeguarding team also gave positive feedback about this practice to the CQC.

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 always did so with integrity, openness and honesty. Staff told us leaders in the practice were visible and approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. For example, the leaders were always available to listen to any query from the staff and provide needed support daily at the practice. The practice also pioneered extended hours hub during the weekend in the local area.

The service fostered a positive culture where people felt they could speak up and their voices would be heard. The service had established Freedom to Speak up arrangements with the local primary care network. Staff were aware of how to raise concerns internally and externally. Staff knew that the leaders were open and could be approached with any of their concerns.

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. Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to the work environment to support staff with mobility needs.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

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. For example, staff raised their concerns that were clinical and non-clinical with the leaders and had confidence that they would be addressed quickly. Clinical staff had supervision with additional support and guidance provided where needed. We saw evidence of documentation of these supervisions.

The service clearly understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. The service worked with other practices within the primary care network to offer extended access, and vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services and voluntary organisations. The service engaged with the patient population, including the patient participation group (PPG) to improve service delivery. The contributions made by this practice was recognised by the Mayor of the local community who awarded them an award for the great services to the local community in 2023. In addition, the leadership of the service shared their learning and findings with other healthcare professionals to improve primary care delivery. 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.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The service was proactive in improving the quality of the service received by the patient population through audits of systems and several clinical audits.

Learning from these audits led the practice to create templates and toolkits used by the practice and shared with other practices within the local primary care network. These reviews and audits subsequently led to an improvement of the patient health such as palliative care patients and women who had never attended cervical cancer screening before or in many years. In addition, other patients were given targeted information especially, patients from ethnic backgrounds and who were at risk of experiencing poor care. The practice operated on the ethos of improving the health of the local community. For example, there has not been any incident of a missed diagnosis of cancer in the past 2 years.

Another example was the decision tool template created by the practice to help the clinical staff ask the right questions to ensure the right decision was made with patients who needed combined oral contraceptives and hormone replacement therapy. The tools were created because of a significant event that occurred with patients who required hormone replacement therapy and or combined oral contraceptives. The practice utilised the processes available on the clinical system used by the practice. The tools were built into the clinical system used by the practice to make it a standardized approach for all clinical staff at the practice to avoid prescribing errors and ensure the right decision on treatment option was made for the patients.