Cape Hill 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.

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.

The practice had a mission statement which was displayed within the practice. The mission statement highlighted the practice wanted to provide high quality whole person care, respecting the life, faith and dignity of the individual. The practice set out to be our patients’ advocate, and solve their problems, aiming to listen, learn and educate. An action plan was in place to address the low patient satisfaction scores from the GP national patient survey. For example, an increase in the number of staff answering the phones during peak times and updated customer service training for reception staff.

There was an open culture and clear learning within the practice. Regular meetings were held with staff, and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

Staff reported a positive experience of working at the practice. Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care. Team members highlighted effective communication and stated that they felt included in decision making processes relating to the service.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. The staff records we viewed showed equality and diversity training had been completed.

Staff had access to clinical supervision, learning and development events as well as educational support and all staff had access to online learning systems. The leadership team provided regular reflective practice sessions and enabled flexible working where able. The practice was a training practice for GP registrars and medical students.

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 that their wellbeing was considered, and their views respected, and concerns acted upon. Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve. Staff we spoke with on the day of the assessment were aware of how to access the free to speak up guardian if they had any concerns.

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.

All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation and clinical supervision was in place. There was an induction process in place for newly appointed staff and staff told us that they were well supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available. Policies and procedures to promote diversity and equality were in place.

The service had governance systems and accountability arrangements in place; however, these were not always effective in identifying and mitigating risksTThey did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had some established governance processes that were appropriate for their service. Staff could access all required policies and procedures. 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.

We found some governance processes required strengthening to ensure risks were mitigated. These included effective processes in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA), high risk medicines, staff immunisation status and the relevant checks for newly employed staff.

Managers met with staff regularly to complete appraisals and performance reviews; however, we found on reviewing staff personnel folders that there were gaps in training updates. Following the onsite assessment, we received evidence to demonstrate that staff had completed training updates.

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.

Leaders told us they worked with stakeholders and the local community. The practice was part of a Primary Care Network (PCN) which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

The practice offered extended access, flu and covid vaccination programmes. Staff had made adjustments and collaborated with local services to further support community healthcare services. For example, providing support to nursing homes, with regular ward rounds to provide care and support to those at higher risk of hospital admission. The practice had also organised a health and wellbeing event in conjunction with community services to provide support and information to the practice population.

The practice had not had an active patient participation group (PPG) since the pandemic, which limited opportunities for ongoing patient involvement in service developments. The management team worked and followed the advice provided by the involvement specialist at the ICB and were actively encouraging patients to join. We found information was available in a range of languages in the reception waiting area to encourage patients to join the group and information was also available on the practice website.

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 leadership team held weekly staff meetings to share learning from incidents and complaints and monitor the quality of the services provided. An action plan was in place to improve areas that had been identified as requiring improvement through the GP national patient survey. This included increasing the number of staff answering the phones at peak times. We found staff training was not up to date, however following the onsite assessment we received assurances that this had now been completed by all staff.

The practice had a quality improvement plan in place to help drive service delivery. This included regular monitoring of the appointment system. The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.

The clinical team had been involved in a range of clinical improvement projects. For example:

• To reduce cardiovascular health inequalities and improve the management of hypertension. The practice had been the project lead and had organised a team approach to support cardiovascular case finding. The team included local pharmacies and 2 community centres.

The practice fostered continuous professional development across all staff groups, with clear evidence of internal career progression, including staff advancing into lead roles. The ongoing development of skills, knowledge, and competence was seen as essential to delivering high-quality, safe care, improving access, and supporting long-term sustainability. Staff were actively supported to acquire new skills and share best practice.

The practice was a well-established training site and they worked closely with partner organisations to support the development of future healthcare professionals, including GP registrars, foundation doctors and medical students.

Further evidence provided showed the practice staff had been involved in a range of events. These included:

• A women’s wellbeing event in June 2025. The event was held to provide information to females in the local community and a range of community services joined the event, for example public health and Age UK. A total of 133 patients attended the event. Following the event, 3 patients received blood pressure readings, 3 patients attending cervical screening appointments and 5 patients were referred for weight management. Another 50 patients were signposted to a range of local services to improve health and wellbeing. These included physical activity, stop smoking services and diabetes UK.
• The practice had developed a maternal health service called the Ayub project to provide support to womenduring pregnancy and the first years of their child's life. An audit was completed to identify patients that would benefit from a personalised approach. The audit found 12 patients had had a previous poor outcome in pregnancy, 10 patients had concerns related to safeguarding and 21 patients had a comorbidity- including thyroid disease, hypertension, diabetes and a raised BMI. The practice contacted all female patients aged between 18 to 50 years who had a long-term condition to provide them with information they would need to consider if they were planning a pregnancy. The social prescribing team ran the project alongside the midwifery antenatal sessions. The wider clinical team were also able to refer to the social prescribers in the first year of a child's life for further support if required.
• The practice had actively been involved in the Workwell project with 2 other practices within the Primary Care Network (PCN). The aim of the project was to reduce long-term sickness absence and support patients to remain in or return to work with referrals to local support organisations. At the time of the onsite assessment, the practice had referred 19 patients and 25% of the patients had progressed through the programme and were looking for work.