Bilbrook 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 outstanding. At this assessment, the rating has changed to good.

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 service 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.

Feedback from service users was shared with the team and celebrated. Staff understood the service vision and there was a culture of teamwork and support amongst all the staff. Staff told us that it was a great place to work where they were encouraged to share ideas. Medical students and trainee doctors fed back that they always felt supported, and were able to access leaders for reviews and discussion. Leaders demonstrated an open culture where all staff were treated equally in a kind and encouraging manner.

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 service were approachable, kind and encouraged open honest conversations. We saw the leadership team worked with other practices in the Primary Care Network (PCN) and were engaged in the development of primary care services within the local area.

Staff, including students on placement told us that they felt very comfortable approaching leaders and the leadership team encouraged them to share ideas and experiences for learning and reassurance across the team.

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 within the Primary Care Network (PCN). Staff were aware of how to raise concerns and were confident that these would be treated with fairness and confidentiality.

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.

Policies and procedures to promote diversity and equality were in place. Adjustments were made to ensure a good working environment, such as change in work hours or adapted equipment for an individual based on a health need, requests were treated fairly and equally.

Clinical staff had all received a documented appraisal, however non clinical staff did not have documented evidence that appraisals had taken place, staff did tell us they had all been given the opportunity to discuss their work and development informally and were happy that their development plans, work and achievements had been recognised by leaders.

The service did not always have clear systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Oversight and assurance relating to some areas required review to ensure compliance. For example, the defibrillator had not been tested as part of the annual equipment checks, there were no documented checks in place that would have identified this. Areas such as health and safety compliance had been completed by external services, however the service leaders had not checked for documented evidence to ensured they had full assurance. Assurance oversight required further review within the leadership team, for example clinical reviews and actions from safety alerts were not always actioned. Health and safety checks required an assurance process to ensure all actions were completed, such as equipment annual testing. Review and auditing of processes had some gaps, such as a lack of evidence that regular checks were being completed on medicines, including emergency medicines to ensure stock levels and expiry dates were safely monitored.

Clinical staff had annual appraisals completed as well as daily supervision and support, however there was no evidence of non-clinical staff appraisals being completed.

Staff took patient confidentiality and information security seriously and were able to demonstrate this.

Leaders held regular meetings with staff, during which they discussed concerns, updates and emerging risks.

Staff feedback was they felt supported and understood their roles within the service. Staff could access all required policies and procedures and there was an employee handbook which provided oversight of key staff processes and policies. There was a business continuity plan in place with key information required for various situations that may impact service provision.

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.

The service worked within their PCN to offer extended access. Staff had made adjustments to improve coordination of their service with community healthcare services, including the local hospice and district nurses.

The service had supported local district nurses in prescribing and advanced practitioner courses by providing clinical supervision and assessment.

Feedback from members of the Patient Participation Group (PPG) was positive expressing that staff and leaders were kind and caring and they felt listened to. The group had a small number of members and there hadn’t been any official face to face meetings since they stopped during the Covid-19 pandemic, this was fed back to the leaders and they acknowledged that this could be implemented again and it may encourage others to join the PPG.

The service worked closely with two local care homes, the feedback received from them was positive describing effective communication, a trusted and kind service where the residents felt listened to and cared for. The care home staff felt supported by the service and they worked well together.

Staff were aware of local support groups and demonstrated examples of when they would signpost service users to them, there were also posters available in the waiting area with the information, such as Women’s Aid drop in sessions and the local Macular Society Group.

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 contribute to safe, effective practice and research.

The service was a proactive training hub with many opportunities to gain experience and develop. There were structured meetings as well as supervision available during the working day. We saw evidence of shared learning and development within the team, for example a recent presentation led to further education on sick day rules and guidance to follow when a person on certain medicines or treatment for a long term medical condition has an illness that effects their medicine intake such as vomiting.

A project had been completed to explore the limitations of the screening systems and measures had been put in place to support transgender and non-binary service users to understand available screening and how to access the services.

The service leaders actively encouraged a range of clinical audits, there had been a recent audit on the prescribing and use of opioids, a group of medication primarily used for pain relief, to ensure safe prescribing and reduce the risks of overuse. Audits had been completed on minor surgery and anti- coagulation treatment (medicines that reduce the risk of blood clots) which included shared presentations, reflections, and outcomes.