The Limes 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.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Staff reported feeling supported by leaders, and there was evidence of openness and a willingness to improve.

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.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

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 and adjustments had been made to ensure all staff were valued.

The service had clear responsibilities, roles, systems of accountability and good governance. However, we identified several areas requiring improvement. For example, the fire risk assessment was not up to date, there was no effective system in place to monitor blank prescriptions, some staff had not completed all mandatory training, and out-of-date consumables were found in surgery. The practice responded promptly and took immediate action to address all identified issues.

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. Staff could access all 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. Staff took patient confidentiality and information security seriously.

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

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. The practice also engaged with community-based services such as social prescribing and health improvement programmes, supporting patients with wider health and social needs and addressing local population challenges.

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 quality improvement plan in place to help drive improvements in services This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working, for example a sustainability plan had been put in place to reduce paper wastage.

The practice demonstrated a proactive approach to quality improvement. For example, a quality improvement project was completed to make sure patients with chronic kidney disease (CKD) were being monitored and recorded properly. They found that some important checks, particularly urine tests, were not always being done, and patient records were not always coded correctly. To improve this, the practice introduced simple tools such as quick-reference guides for clinicians, training sessions, and information for patients to encourage them to attend tests. These changes led to clear improvements, with more patients receiving the right checks and records being updated more accurately.