Pontesbury & Worthen 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 the service met people’s needs, and that staff treated people equally and without discrimination.

At our last assessment, we rated this key question as Good. At 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 service had a shared vision, strategy and culture which was to be recognised as a leading provider of compassionate, accessible, and safe healthcare in their community. Their mission was to deliver holistic, evidence-based care that improved health outcomes, respected patient choice and fostered trust. The practice had identified strategic objectives which included enhancing patient access and experience, including timely appointments.

Staff we spoke with were aware of the practice’s vision and were proud to be part of a team that offered patient centred and compassionate care. We saw evidence that the practice applied their values during their work as we observed staff being caring and supportive to their patients.

There had been a change in leadership since the merger of both sites in April 2021, to help future proof local services for patients.

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. Staff also told us leaders modelled the values of the practice. 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 had Freedom to Speak up arrangements in place and staff had access to a policy to follow should they wish to raise a concern. The service fostered a positive culture, where people felt they could speak up and their voice would be heard.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place and were readily accessible. Adjustments had been made to ensure all staff were valued. Staff confirmed that training in equality and diversity was available, which reflected information held on the practice training records.

The service had clear responsibilities, roles and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support.

Staff could access all required policies and procedures. However, governance processes needed strengthening to ensure policies and procedures were followed and embedded into practice. For example, we found that prescriptions were not always signed in line with national guidance, staff not following provider's own procedures when reporting near misses in relation to the dispensing of medicines and checks of controlled drugs (CD) not undertaken at the required frequencies. We also found that the practice's own recruitment policy was not always followed either. 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 provider had not displayed their CQC rating at their branch site or on their website as required. However, they confirmed they had since actioned this.

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

The provider worked proactively with other practices within their primary care network (PCN). Two of the partners were involved in establishing the Integrated Care Board (ICB) and one remained actively involved. One of the GP partners was currently the Local Medicines Committee (LMC) chairman, and another partner was the clinical director for the PCN. Extended hours clinics were available at Pontesbury, provided by the PCN on Saturday mornings where a range of clinics were offered. These included, dressings and general nursing care, chronic diseases reviews, pharmacist-led structured medication reviews, women’s health services as well as a GP-led clinic.

The practice focused on continuous learning, innovation and improvement across the organisation and local system.

The practice had a quality improvement plan in place to help drive improvements in services. For example, following the results of the GP patient survey the practice had identified the need to review their website and planned to involve patients in this work. They had also reviewed patient access and were in the process of recruiting another GP to increase the number of appointments available. The partners had also decided to employ an additional member of staff to the administration team to provide support and was also exploring a digital solution that could potentially improve recall processes.

As a training practice, they offered supervision of trainee doctors and invested in staff development. For example, one of the nurses was undertaking the fundamental in practice nursing qualification.