Leicester Terrace Health Care 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. We found there was an inclusive and positive culture of continuous learning and improvement shared by all staff. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated and person-centred. There was a system of governance that aimed to manage risks and keep people safe.

At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to good.

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.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

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.

The mission of the practice was to provide quality, accessible, and compassionate care that puts people first. Staff understood the values of putting people first, treating them with dignity, and working together to provide safe and compassionate care. Leaders made sure these values were part of everyday practice rather than just statements on paper. The culture was open and respectful. Staff described feeling valued and motivated in their roles, with leaders who listened and recognised their contributions. Staff told us they felt included and supported. They said managers were approachable and encouraged them to share ideas or raise concerns. Regular meetings and supervision gave staff time to reflect on their work, learn from each other, and stay focused on what mattered most to the people they supported.

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 with other practices in the Primary Care Network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect. The service had an open culture where staff felt confident to speak up if they had concerns or ideas for improvement. Staff told us they were listened to and felt safe raising issues without fear of negative consequences. Leaders promoted honesty and transparency, encouraging staff to share concerns early so they could be addressed quickly. There were clear policies in place, and staff knew how to access them if they wanted to raise a concern formally. Regular team meetings and supervision sessions gave further opportunities for staff to talk openly about their experiences.

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 the wellbeing of staff. The service promoted a culture of equality, diversity, and inclusion. Leaders ensured staff were recruited fairly and valued for their skills, knowledge, and personal qualities, regardless of background or personal circumstances. Policies and procedures supported equal opportunities, and staff told us they felt respected and treated fairly. Training in equality and diversity was provided, and staff understood the importance of creating an inclusive environment both within the workplace and in the care they delivered. Staff said the service encouraged openness and respected individual differences, which helped build a positive and supportive team culture.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Practice leaders held clearly defined lead roles, which were further supported by administrators assigned to specific lead responsibilities within the practice. This structure made the governance framework transparent, allowing all staff to understand who was accountable for various areas. Staff were confident in their individual roles and responsibilities and could clearly explain the overall governance system. Regular appraisals and performance reviews were conducted for all staff, with thorough documentation and actionable development plans in place. The provider had established robust and detailed governance processes to maintain comprehensive oversight of all practice activities. Evidence showed that audits were routinely completed to ensure staff compliance with policies and procedures. Any identified areas for improvement were treated as learning opportunities to promote continuous practice-wide enhancement. The governance and oversight of the practice were strong, supported by clear, well-maintained documentation. Regular practice meetings were held to discuss clinical concerns and emerging risks, with thorough records kept and communication disseminated to ensure all staff remained informed and supported in delivering safe patient care. Additionally, staff demonstrated a strong commitment to always maintaining patient confidentiality and information security.

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 collaborated for improvement.

The provider actively collaborated with other practices within their Primary Care Network (PCN) to deliver extended access services and flu vaccinations. To enhance coordination with community healthcare services, staff implemented adjustments that included establishing weekly multidisciplinary meetings focused on the care of patients at higher risk of hospital admission. These efforts improved communication and care planning. Staff worked collaboratively with Pharmacy First scheme, Northamptonshire Association for the Blind, Deaf Connect, the learning disability team, and the local homeless centre to support better health outcomes for vulnerable patients through more integrated service delivery.

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, effective practice and research.

Staff told us they were supported to identify learning from incidents, complaints, patient feedback, and that improvements were shared across the team to ensure consistency in care. Regular audits were carried out to monitor the quality and safety of services, with clear action plans put in place where improvements were needed. Leaders tracked progress against these plans and ensured staff were involved in implementing changes. The provider had a structured Quality Improvement (QI) plan in place, underpinned by recognised methodologies to support ongoing service development. Members of the PPG were actively engaged in QI working groups, ensuring that patient perspectives informed decision-making and service changes. Recent initiatives focused on enhancing the in-house document workflow and urgent care triage system, leading to improvements in staff efficiency and patient satisfaction.

Innovation was encouraged, and staff had access to training and development opportunities to build new skills. Managers supported the use of digital systems to streamline processes, such as record-keeping and communication, which improved efficiency and reduced the risk of error. Leaders engaged with local networks and professional forums to share best practice and keep up to date with developments across health and social care. This supported a culture of openness and learning from the wider system.