Bellingham Practice Also known as The Bellingham 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 service’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 outstanding. At this assessment, the rating has changed to good.

This service scored 87 (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, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

Leaders promoted engagement through quarterly whole-practice meetings, where staff discussed service priorities, developments and future plans. The service also engaged with people through its Patient Participation Group (PPG), which met quarterly.

Leaders were aware of local challenges that could affect the service, including projected population growth associated with new housing developments. They had secured funding to reconfigure existing premises and create 2 additional clinical rooms to help meet anticipated increases in demand.

Team meetings provided opportunities for learning, reflection and staff support, including discussions following significant events and challenging incidents. Staff and leaders actively promoted equality and diversity and demonstrated a positive and compassionate culture focused on learning, wellbeing and continuous improvement. The practice was a GP training practice and supported the development of future healthcare professionals, including GP registrars and medical students.

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 service had governance systems and processes in place; however, these were not always sufficiently effective to provide assurance that risks were identified, monitored and managed.

Some clinical rooms remained in use without hot water. Although staff described measures to reduce the risks, we did not see a documented risk assessment during the assessment and there was no signage in the affected rooms. It was also not clear how the practice assured itself that the person who completed the Legionella risk assessment had the appropriate training and knowledge to undertake the role. Following the assessment, the provider submitted additional evidence about the management of the flood related risks and confirmed that future Legionella risk assessments would be undertaken by an external contractor.

The practice had received a small number of complaints. However, there was no central system for recording key information such as dates received, responses, actions taken and learning identified. This limited the practice's ability to monitor trends and provide assurance that complaints would be managed consistently if numbers increased. The practice told us it was considering introducing a complaints tracker to strengthen oversight.

Oversight of recruitment records required strengthening. During the assessment, evidence of identity checks was not available in 1 recruitment file reviewed. The provider supplied copies of the staff member’s identification later that day.

Leaders held regular meetings with staff where risks and service improvements were discussed, and actions were recorded and shared with the team. Staff had access to policies and procedures which were reviewed and updated. The practice had a business and development plan covering finances, contracts, workforce and future priorities, and a business continuity plan which had been recently reviewed.

The practice used audit and quality improvement to identify areas for improvement and monitor changes. An audit identified under-recording of military veterans. Following action to improve identification and coding, the number recorded as veterans increased from 61 (1.8%) to 91 (2.9%). A separate frailty audit identified under-recognition and inconsistencies in coding. The practice introduced a structured approach to identification, assessment and multidisciplinary review. Recorded frailty increased from 1.7% of the practice population in March 2025 to 3.1% in August 2026.

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.