Woodsetton Medical Centre

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 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 shared vision, strategy and culture. This was based on serving the community; with the resources available to achieve the greatest possible improvement to the physical and mental health of the practice population and to provide a working environment in which all members of staff are encouraged to achieve maximum potential, in order to provide high quality healthcare.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Team members stated that they felt included in decision making processes relating to the service and that leaders were visible.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

There was an open culture and clear learning within the practice. Regular meetings were held with staff, and the management team encouraged the reporting of incidents to identify ways in which the practice could continually 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.

Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

The practice had a positive culture where people knew they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with a clear and detailed policy staff could follow. Staff confirmed they were aware of how to raise concerns outside of the organisation. Staff had received training in whistleblowing.

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.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available.

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 share 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.

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.

Leaders reported that they worked closely with stakeholders and the local community. The practice was part of a Primary Care Network (PCN), which provided enhanced services to patients. The PCN met regularly to deliver services aligned to patient needs and to support care provision and service development. Projects within the PCN included minor surgery, work on undiagnosed osteopetrosis, the creation of a neighbourhood hub as part of the NHS 10-year plan, and delivery of COVID-19 vaccinations.

The leadership team recognised the increasing demand for services and were working collaboratively with the PCN to ensure resources were planned effectively. This included capacity planning and improvement initiatives as part of Modern General Practice.

At practice level, regular staff meetings were held to support collaboration and drive improvements in patient care and treatment. Although uptake was low, a Patient Participation Group (PPG) was in place, and the practice also engaged with a wider PCN PPG to ensure patient views were represented at locality level.

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 contributed to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive service delivery. This included regular monitoring of the appointment system. The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.

The leadership team held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided.

The practice was veteran accredited and registered as a safe surgery. In addition, a recycling programme was established to reduce environmental impact and support sustainability within the community.