The Eaglescliffe 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 outstanding. At this assessment, the rating has changed to good. At this inspection we found that some of those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. While the provider had maintained this good practice, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing well-led services.

This service scored 82 (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.

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.

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 leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice, and described actions leaders had taken to support staff. We saw evidence of practice leaders engaging with staff on changes made within 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. We saw feedback from students, GPs in training, local services, representatives from the PPG, and partner agencies that described caring and innovative leadership at the practice. Leaders were proactive in seeking out partner agencies and organisations that could support in promoting the best outcomes and services for patients.

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.

The service valued diversity in their workforce. They worked 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. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

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 clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Practice leaders worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes.

We saw evidence that leaders from the practice worked closely with local services and other GP Practices within the PCN to provide support, on a service level as well as on a personal level. Leaders from the practice had sought feedback from local services, which was positive and described the practices engagement with initiatives and partnership working. The practice’s social media channels included collaborations with local services such as a local school, and a community activity group.

Practice leaders were committed to obtaining feedback from partners and community links. We saw positive feedback from representatives of the PCN in this area, detailing the contributions practice leaders had made to the development of local primary care services by attending monthly PCN meetings and sharing learning. For example, leaders had arranged training for staff on learning disabilities and had shared this knowledge with the PCN. We also saw feedback from a local practice leader, who praised the management at The Eaglescliffe Medical Practice on their mentorship and informal support of other leaders in the local area.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 their services. This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working.

We saw evidence of changes that had been made to improve access to the practice, such as the introduction of an online service that could be used to contact the practice, and changes to the telephone system. The practice was part of the wider research team with a local health organisation.

This practice facilitated the training of GP registrars. We saw feedback from previous GP registrars who had described the supervision received from their supervisor as excellent.

The practice had supported and participated in the Children and Young People’s Mental Health Practitioner pilot. This involved collaboration with other services and reviews of best practice guidance in order to provide a mental health service which leaders had recognised was needed for the children and young people of the local population. Since our last assessment, the social prescribing service had been extended to include children and young people as well as adults. In the past 12 months, there had been 288 social prescribing appointments available at the practice, and 32 young people had been referred to this newly available service. The practice had held drop-in sessions for people to access a social prescriber. We saw positive feedback that had been received by the practice from people who had used this service. This included people describing the positive difference social prescribing had made to their lives, such as feeling less alone, exploring different support options, and feeling increased self-confidence.

Leaders at the practice were involved in research around the use of social media in public health education and referral pathways. The practice produced social media videos to promote referrals to the NHS Type 2 Diabetes service. From this there was a large increase in the number of patients who used this service. The leaders were scheduled to present this research and promotion at a national conference. Practice leaders shared knowledge at regional meetings, particularly focused on the use of technology in primary care.

Representatives from the PPG described the practice leadership as innovative and caring.