Bishop's Close 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 the provider’s leadership, management and governance assured high-quality, person-centred care and promoted an open and 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 provider had a shared mission, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

Leaders monitored and reviewed progress against their mission, values and strategy. Their mission statement described “an enthusiastic, well organised practice committed to providing high quality patient care”, with patients at the centre of everything they do. The statement also described aims for providing staff with an “an enjoyable, supportive workplace where staff can develop their skills, achieve their potential and experience high levels of satisfaction”

Leaders recognised that projected population growth and increased visibility due to town centre changes were likely to increase demand for services and had considered these factors in future planning.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development. Staff were extremely positive about the culture within the practice, confirming they were well supported and enjoyed working as part of a team. They described the culture as open and transparent, and said they felt confident raising concerns, knowing these would be listened to and acted upon.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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

The provider had established governance processes for most of the quality statements reviewed during this assessment. However, arrangements for monitoring mandatory training and staff immunisations required further strengthening to provide effective oversight and assurance of compliance. Leaders responded promptly to the findings of the assessment, taking immediate action to address identified gaps. Improvements had already been implemented, with additional measures planned to further strengthen governance and monitoring arrangements.

All staff we spoke with were clear about their individual roles and responsibilities. Staff told us the leaders had an “open-door” policy and were responsive and available to provide support when needed. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. There was a strong emphasis on staff wellbeing throughout the organisation, reflected in the practice's mission statement and supported through its leadership approach and engagement with staff.

Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the practice. Leaders clearly recorded any actions that arose from these meetings and shared these with staff.

Managers regularly reviewed significant events and complaints to identify themes, trends and opportunities for improvement. Learning from these reviews was shared with staff to support practice development. Staff also undertook an annual review of complaints and significant events, which was discussed at a dedicated staff meeting to promote reflection, shared learning and continuous improvement.

Staff took confidentiality and information security seriously.

Staff submitted data and notifications to external agencies as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.