Killamarsh 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, we rated this key question as Good. At this assessment, the rating remains the same.

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, engagement, and understanding challenges and the needs of people and their communities. Staff had not contributed to the development of the practice vision and strategy, however, most staff were aware of the service’s mission statement.

The service was aware that the practice population had a higher number of older people registered with the practice compared with the national average and was working with partner agencies to address future challenges. For example, the social prescriber, dementia support services and carer’s support.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. Due to a high number of older people registered with the practice, leaders had tailored services to meet the needs of this group of people. The care co-ordinator supported and co-ordinated these services. The practice had been awarded the Carer Friendly Practice Quality Mark in recognition of this work.

Staff told us leaders in the practice were very approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. 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 provider and staff told us of examples of when reasonable adjustments had been made to support staff to carry out their role. For example, flexible working patterns and adjustments to meet both physical and mental health conditions.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns and who the Freedom to Speak up Guardian was. Posters were displayed throughout the practice and there was a policy in place to support this.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles and systems of accountability. Staff were aware of who to go to for support and guidance.

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. Staff could access all of the required policies and procedures. 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 lead practice nurse attended the receptionists’ meetings to enhance understanding and communication between the 2 staff groups. Staff took people’s confidentiality and information security seriously.

There were governance processes in place, however these needed to be strengthened to ensure that policies such as safeguarding and medicines management contained sufficient details to support staff. The complaints policy had not been updated to reflect that people could submit their complaint to the Integrated Care Board. This changed from NHSE in July 2023. Policies were not always dated to show when reviews had been completed or were due. A risk log had been developed in response to findings during our assessment. However, all of the required risk assessments had not been completed. For example, legionella and health and safety. Following our assessment the provider sent us risk assessments and a date for the legionella risk assessment to be completed by an appropriate company.

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. We received positive feedback from 2 care homes where the service provided care and treatment. They told us that the service was prompt in answering any issues people living in the homes had and ensured good continuity of care for their residents.

The provider worked with other practices within their primary care network to offer extended access. They had identified key partnerships to support their older population. For example, the Living Well Programme, the Killamarsh Active Exercise by Referral service and the Citizens Advice Bureau.

The service worked in partnership with the Patient Participation Group (PPG). A representative of the PPG told us the PPG meetings were informative and kept members up to date with developments within the practice. For example, the introduction of the total triage system had been clearly explained to them. They told us if people raised any concerns, leaders listened and acted on them.

As part of their wider engagement with partners and communities, the practice had invited local Members of Parliament (MP) to their PPG meetings to provide answers regarding health care services on behalf of the Government. The practice manager had also attended the MPs public engagement meetings where key issues were raised about the practice, such as telephone access to the service and a lack of GPs. Action was then taken to address these concerns such as a new telephone system and the recruitment of 2 new GPs.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They used complaints, significant events and clinical audits to drive improvement within the service. However, second cycle clinical audits were not in place to demonstrate if changes made had been effective.

Leaders encouraged creative ways of delivering equality of experience, outcome and quality of life for people. All staff were encouraged to put forward and test out new ways of working. For example, one of the practice nurses had been instrumental in reinstating the mobile breast screening service back into the local leisure centre to improve access for people. Changes to the recall systems for screening had resulted in the practice exceeding the national cervical screening target of 80% and childhood immunisation targets.