Lower Gornal 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 Good. At this assessment, the rating has changed to requires improvement because:

The practice had established systems and processes; however, these lacked adequate oversight. Although leaders demonstrated the capacity and skills required to deliver high-quality, sustainable care, certain aspects of accountability remained deficient. Governance required further enhancement to ensure that processes for managing risks, issues, and performance were both comprehensive and robust. Moreover, while structured systems or mechanisms were in place, they did not sufficiently foster a culture of learning, continuous improvement, or innovation.

The service was in breach of legal regulation relating to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The majority of staff reported a positive experience working at the practice, describing strong teamwork, supportive leadership, and a shared commitment to delivering high-quality, patient-centred care. A stable workforce was evident, with low staff turnover contributing to continuity and service reliability. However, some challenges were noted within the senior leadership team, which occasionally impacted cohesion and strategic oversight.

The practice had recently introduced a charter reflecting its values, including transparency, equity, equality and human rights, diversity, inclusion, and staff engagement.

While Friends and Family Test (FFT) results were shared monthly with staff, other feedback such as complaints, significant events, and patient survey outcomes were not consistently communicated, which limited opportunities for shared learning and service improvement.

Leaders were supportive, approachable, and responsive to concerns raised by staff. They demonstrated a level of understanding and experience of the context in which the service delivered care, treatment, and support; however, this required further development. Senior leadership operated on a part-time basis, which contributed to delays in communication and decision-making.

There was an absence of regular business meetings focused on succession planning and strategic progression. Although leaders possessed the necessary skills, knowledge, and experience, fractured relationships among staff undermined cohesion and operational effectiveness. Nonetheless, the leadership team acknowledged existing areas for improvement and expressed a clear commitment to advancing the service and implementing positive changes.

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 and staff were aware of how to raise concerns.

Leaders at Lower Gornal Medical Practice 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 to promote diversity and equality were in place. Adjustments would be made to ensure all staff were valued. We observed that interaction between team members was positive and relaxed

The service did not always have clear responsibilities, roles, systems of accountability to manage governance and sustainability. Staff indicated that communication required improvement, with notable inconsistencies regarding accountability and oversight. Several systems and processes required further embedding to ensure resilience and consistency, particularly in areas such as clinical oversight, safeguarding, staff immunisation, patient group directions, training, and staff competencies.

Although meeting minutes were shared by the practice, this was inconsistent, and staff expressed a desire for more regular meetings to enhance internal communication. We found some governance processes needed strengthening to minimise risks. The provider did not maintain adequate oversight of monitoring all systems.

While staff training processes were subject to monitoring, gaps in completion were identified, with some staff reporting insufficient time to fulfil training requirements. Additionally, concerns were noted in the handling of complaints and significant events, highlighting a need to recognise recurring themes, share lessons learned effectively, and ensure that resulting actions were properly implemented and actions taken.

While leaders and managers had introduced operational and clinical governance procedures, these were not consistently aligned with the delivery of safe and effective care. For instance, non-medical prescribers had been delegated responsibility for reviewing pathology reports. Although nurse meetings, led by the Advanced Nurse Practitioner (ANP), had occurred, they lacked consistency. In addition, systems for assessing and validating nurses’ capability to practice at an advanced level remained limited.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. The practice actively engaged with the Primary Care Network (PCN), worked closely with PCN staff, and worked with other practices within the PCN to offer additional services, such as extended access. As part of the assessment, feedback was obtained from a representative of the Patient Participation Group (PPG). The PPG met up to four times annually and collaborated closely with practice management. Together, they produced a newsletter three times per year to inform patients about services available within the practice and the wider community. They actively engaged in community initiatives to promote health awareness, including educational events around dementia and upcoming talks focused on stroke prevention and care. They described the practice as transparent and responsive and were kept up to date with information such as the friends and family results.

As part of the assessment, feedback was gathered from a Patient Participation Group (PPG) representative. The group held up to four meetings annually and worked in close partnership with the practice management team. They produced a newsletter to keep patients informed about available services both within the practice and across the wider community. The PPG actively supported community health initiatives, delivering educational events on dementia and planning future sessions on stroke prevention and care. The representative described the practice as transparent and responsive, advising they were regularly updated with information such as Friends and Family Test results.

The practice operated as a training environment, with a designated GP responsible for overseeing the development of trainee GPs. Structured time was allocated for case discussions, observed consultations, and topic-based teaching sessions.

However, opportunities for ongoing learning were not consistently extended to all staff within the practice. In particular, areas such as clinical oversight and audit of consultations lacked regular and systematic engagement across the wider team.

Staff worked with the Primary Care Network (PCN) to deliver a wider range of services and we saw evidence that an audit had been carried out on minor surgery.