Chapelthorpe 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.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment.

Staff understood their roles and responsibilities. However, we found some issues with governance arrangements across some areas.

Managers worked with the local community to deliver the best possible care and were receptive to new ideas.

At our last assessment, we rated this key question as Good. Following 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 practice had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders told us how they used meetings to discuss values and explained how it was important to them that staff felt valued as employees. We heard examples of how staff had been supported with personal issues. All of the staff we spoke with and received feedback from were positive about working at the practice.

The practice was aware of issues with staffing levels within the non-clinical teams and had taken steps to address this.

Leaders told us how they fully utilised all additional support such as the pharmacy first scheme and physiotherapists to support the increased demand for clinical services.

The practiced was focused on creating a welcoming culture for patients and listened to feedback to improve the service. For example, at the time of our assessment, leaders were in the process of sourcing training to ensure staff were able to better support transgender patients.

The practice 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. The practice held daily huddles for non-clinical staff to ensure any issues could be identified and addressed, the daily duty doctor was situated within the reception area to provide support to staff throughout the day.

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.

The practice 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 the local GP federation. Staff were aware of how to raise concerns and felt comfortable in doing so.

The practice 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. We saw leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, menopause champion support had been introduced, staff had access to counselling and other support services, and wellbeing was included in appraisals.

The practice did not always have clear responsibilities, roles, systems of accountability or good governance. For example, the practice used an electronic knowledge, compliance and workforce management system. During our site visit we reviewed staff training records on the system and found that certificates had not been uploaded to evidence training had been completed. The provider shared certificates with us following our inspection.

We found Patient Group Directions (PGDs) were in place to allow nurses to administer medicines to a pre-defined group of patients. However, these did not always contain details of the practice in line with requirements. We found that in some cases the authorising signature was dated after the staff members had signed them.

We found Patient Specific Directions (PSDs) were in place, allowing medicines to be administered to a list of individually named patients. However, in some cases these had been signed after the medication had been administered.

We looked at the vaccination refrigerators and found that not all of these had a list of stock contained within them.

We found there was a process in place for monitoring urgent cancer referrals to ensure patients were offered an appointment within appropriate timescales. However, there was no process in place to follow up patients who did not attend their allocated appointment.

Managers held regular meetings during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings, however feedback from some staff members indicated that these were not shared amongst the wider team. For example, some staff we spoke with and received feedback from were not aware of any learning from significant events or complaints.

Staff could access all required policies and procedures. Staff took patient confidentiality and information security seriously.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network to offer extended access and additional services including physiotherapy, mental health and access to wellbeing coaches.

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. The practice were early adopters of online access, initially introducing their online triage system in 2019. The practice worked with patients and staff to develop the system over the years and the feedback we received as part of the assessment was positive.

The practice participated in the Cardiovascular Disease Prevention Audit (CVDPREVENT). This enabled them to access data and tools to improve the cardiovascular health of patients. As a result of this work, the practice had been asked by the NHS West Yorkshire Integrated Care Board (ICB) to give a presentation and share examples of the good practice adopted that had contributed to the good outcomes achieved. In addition, the practice had ranked within the top 5 practices in West Yorkshire in achieving lipid management targets.

The practice was a training practice and at the time of our assessment were supporting 3 trainee GPs.

During our assessment process, the provider produced an improvement plan which addressed the areas we had identified and had clear timescales for completion.