Mayfield 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 transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
According to the feedback from staff, there was an open and honest culture within the service. Staff felt confident to raise concerns without fear of retribution and believed that their views were listened to and valued. Staff also said that there was a clear vision for the future.
 

The service had inclusive leaders at all levels who understood the context in which they delivered care and reflected the culture and values of the organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively, and did so with integrity, openness, and honesty. Staff told us leaders were approachable, responsive to concerns, and modelled the practice’s values. We also saw the leadership team working with other services within the Primary Care Network and contributing to the development of primary care services in the local area.

The service promoted a positive culture where staff felt confident to speak up and knew their concerns would be heard. Leaders maintained an open-door policy and encouraged staff to raise issues freely. Staff told us they understood how to raise concerns and felt supported when doing so. The provider had also set up Freedom to Speak Up arrangements with another service in the Primary Care Network, giving staff an additional route to raise concerns without fear of retribution.

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. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

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 act 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 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. We did identify some isolated issues with the oversight of the premises and DNACPR processes, but these were quickly resolved, and oversight of these areas was strengthened. Staff could access all required policies and procedures. Managers held regular 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 clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.
The provider worked with other services within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

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 and effective practice and supported research initiatives, demonstrating a commitment to evidence-based care.
For example, the service reviewed bowel cancer screening protocols and identified opportunities to optimise care and provide individual patient education. These additional steps have since been adopted across the Primary Care Network to improve engagement with non-responders, showing how the service’s innovative approach influenced wider system improvements.