The Bethesda 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

There were not defined and effective systems established to hold staff accountable for their areas of responsibility. Some risks had not been revisited to ensure they had been mitigated and improvements embedded.

The practice culture was founded on inclusivity, listening and valuing the contributions of others to improve the service. Leaders were visible, knowledgeable and supportive and committed to helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff worked with health and social care services to cooperate and improve patient care and well being.

This service scored 71 (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. It also focused on engagement and understanding the needs and challenges of people and their communities. There were established and effective systems in place to promote adherence to the values of the organisation.

Staff told us they cared about their work and were committed to getting it right. They told us they were supported by managers and peers and had access to training and resources to develop within their roles and progress in their careers.

Staff reported that their management team and colleagues demonstrated openness, honesty, and transparency in their interactions with each other and with patients.

Staff told us they were trusted to work with autonomy but had the support and assurance of clinical oversight.

The practice had Speak Up Champions for staff to approach if they felt unable to directly raise concerns with the management team. Staff also had access to external Speak Up Champions if they felt more comfortable to do so. Concerns that were raised by staff were all recorded, investigated and responded to and any learning was identified and shared to drive improvements.

Staff reported that their management team and colleagues demonstrated openness, honesty, and transparency in their interactions with each other and with patients.

Staff told us they were trusted to work with autonomy but had the support and assurance of clinical oversight.

The practice had Speak Up Champions for staff to approach if they felt unable to directly raise concerns with the management team. Staff also had access to external Speak Up Champions if they felt more comfortable to do so. Concerns that were raised by staff were all recorded, investigated and responded to and any learning was identified and shared to drive improvements.

The provider had established governance, management and accountability arrangements in place. Some of the systems required strengthening to improve the safety and efficiency of the practice, in relation to; safeguarding, medicine management, the coding of clinical data and revisiting of risks to ensure they were sufficiently mitigated or removed.

Lead clinicians oversaw risks such as safeguarding, medicine management and clinical practice. The provider conducted checks on individuals or collective prescribing behaviours to ensure adherence to safe practice. This was primarily achieved through audits on their practice.

The provider met with staff individually or collectively to assess and review performance. Lessons were learned from significant events, to help prevent similar incidents from reoccurring. Staff acted on information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had established governance, management and accountability arrangements in place. Some of the systems required strengthening to improve the safety and efficiency of the practice, in relation to; safeguarding, medicine management, the coding of clinical data and revisiting of risks to ensure they were sufficiently mitigated or removed.

Lead clinicians oversaw risks such as safeguarding, medicine management and clinical practice. The provider conducted checks on individuals or collective prescribing behaviours to ensure adherence to safe practice. This was primarily achieved through audits on their practice.

The provider met with staff individually or collectively to assess and review performance. Lessons were learned from significant events, to help prevent similar incidents from reoccurring. Staff acted on information about risk, performance and outcomes, and shared this securely with others when appropriate.

Staff and leaders understood the importance of improvement and how to implement it effectively.

They invested time and resources into listening to people’s experiences and made changes to improve the service. They referred to their patient participation group as critical friends and valued their experiences and contribution to improving the service.

There were established systems and processes to ensure staff learnt from previous adverse incidents, understood the risks, strengthened operating systems or improved people’s skills and knowledge to mitigate or remove the risks from re occurring.

There were established and known processes in place to identify and learn when things went wrong or could be improved. Leaders encouraged and welcomed staff to speak up, employing reflection and collective problem-solving.

Staff and leaders understood the importance of improvement and how to implement it effectively.

They invested time and resources into listening to people’s experiences and made changes to improve the service. They referred to their patient participation group as critical friends and valued their experiences and contribution to improving the service.

There were established systems and processes to ensure staff learnt from previous adverse incidents, understood the risks, strengthened operating systems or improved people’s skills and knowledge to mitigate or remove the risks from re occurring.

There were established and known processes in place to identify and learn when things went wrong or could be improved. Leaders encouraged and welcomed staff to speak up, employing reflection and collective problem-solving.