St James 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 Requires Improvement. At this assessment, the rating has changed to 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 clear shared vision, strategy and culture centred on delivering safe, compassionate and high-quality care to patients and the wider community. Its mission was to provide a friendly, inclusive and supportive environment where patients felt listened to and staff felt valued. The practice promoted a strong culture of learning and continuous improvement, encouraging collaboration, learning from feedback and ongoing development to enhance the quality of care provided.

Staff reported a positive experience of working at the practice. They described a supportive team and a shared commitment to delivering high-quality, patient-centred care.

We found improvements in communication, processes and engagement across the team since the previous assessment. A structured programme of shared learning was in place, including regular team meetings, safeguarding reviews and monthly clinical discussions. The practice used a centralised system to provide staff with access to key documents, audits, learning from significant events and complaints. Leadership arrangements supported resilience and sustainability, with key roles supported through deputy arrangements or shared responsibilities. These improvements demonstrated a positive culture of continuous learning, collaboration and service improvement.

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.

Staff told us that leaders were approachable and supportive, and staff felt comfortable discussing concerns, seeking support, and providing feedback. We saw evidence that leaders were actively engaged both within the practice and across the wider Primary Care Network (PCN), working collaboratively with other practices to support the development of primary care services in the local area. Throughout the assessment, leaders demonstrated a commitment to improving care, and an ability to empower staff to deliver services. We found that deputy responsibilities, cross training and succession arrangements had been strengthened to support operational efficiency.

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. Staff were aware of how to raise concerns.

Leaders encouraged the reporting of incidents to identify ways in which the practice could continually improve.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place.

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 were in place to promote equality, diversity and inclusion. Staff were supported through regular appraisals, one-to-one meetings, coaching, mentoring and revalidation processes. They had access to a range of training and development opportunities, and feedback indicated a positive, no-blame culture where staff felt valued, treated fairly and respected.

The practice also made reasonable adjustments to support staff wellbeing and individual needs, including flexible working arrangements. Equality, diversity and inclusion training was provided to staff, helping to foster a respectful, inclusive and supportive working environment.

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

Following our previous assessment in 2023, the practice had implemented a comprehensive action plan to address the governance concerns identified. We found that the areas requiring improvement had been reviewed and strengthened, with systems and processes established to support the safety of patients and the effective operation of the service. Clinical oversight had been enhanced, including improved monitoring and support for staff in clinical roles, and robust arrangements were now in place for managing staff immunisation records, mandatory training and organisational learning.

The practice had reviewed and strengthened its approach to the management of clinical and operational risks. A central risk and improvement register had been introduced and was subject to regular review and oversight. Named leads were in place across key areas, and staff were aware of reporting and escalation processes, helping to ensure risks were identified, managed and mitigated effectively.

Leaders demonstrated a clear understanding of the governance and regulatory requirements necessary to support the delivery of safe and effective care. Business continuity and emergency arrangements were also in place, providing assurance that the service could respond appropriately to unforeseen events and maintain continuity of care.

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.

Where people required additional support beyond the service, staff could refer them to various services such as a social prescriber for assistance with issues including social isolation, housing concerns, and other factors affecting wellbeing.

The practice demonstrated effective partnership working with local organisations to support people with health conditions or disabilities to return to, remain in and succeed in employment. The service worked well in the Primary Care Network (PCN) and with the local pharmacy to provide a collaborative service to the community.

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.

Since the last assessment, the practice had established a Quality Improvement Team that met quarterly to review performance, identify opportunities for improvement, and assess the effectiveness of systems and processes. The team took a structured and critical approach to reviewing the service, providing oversight and challenge to support ongoing development.

This approach helped ensure that regular quality assurance activities were embedded within the practice and used to drive continuous improvement. Learning from incidents, significant events and complaints was routinely reviewed and used to inform changes to practice, strengthen governance arrangements and enhance the quality and safety of care provided.

The practice operated as a training practice. We saw that the practice worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.