Belmont 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

The practice fostered a well-established, inclusive, and positive learning culture that contributed to better outcomes for patients and the wider community. Learning was actively shared with, and drawn from, external partners to support continuous improvement.

Governance and management systems enabled leaders to monitor risks, performance, and outcomes effectively. Leaders continually sought to improve service delivery, using feedback from both staff and patients to reduce risks and enhance the quality of care. 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 practice had a clear mission statement to “Provide an inclusive, non-judgmental, shared-care approach to patients’ health, powered by hard work and compassion whilst providing a supportive and fulfilling space for staff.” Leaders told us they worked together as a team to revise the mission statement and used a protected time session to collaboratively write the statement using staff input.

The practice had also established set of values which included: “We recognise that our highly skilled staff all have important contributions to make to the practice, so we respect their judgement about what works well in their individual skill areas; We all bring expertise and experience to the team with the ultimate aim of providing good, safe, empathic care to our patients.”

Feedback we received from staff regarding the culture within the practice was mostly positive. 92% of staff told us it was a positive and friendly environment to work in, the culture was open, transparent, blame free and non-discriminatory and they enjoyed working there. 38% of staff however felt that communication within the practice could be improved. This was particularly in relation to communication between the management team and the rest of the staff. Some staff felt they would benefit from more emailed communication regarding any updates in the practice, and other staff reported they felt more face to face communication would be beneficial as this would give staff the opportunity for discussion.

Leaders had the skills, knowledge, experience and credibility to lead effectively.

Leaders actively engaged with patients, staff, and partner organisations to gather feedback and they took meaningful action in response. They demonstrated during the assessment how they made changes for the better wherever they could.

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 strived to ensure staff could speak up and their voice would be heard. There were systems and policies in place to support staff to whistle blow or to speak with a ‘Freedom to Speak Up Guardian’ if they needed to. We saw evidence of a ‘Freedom to Speak Up’ training presentation which had been delivered for staff. The practice had appointed a primary care network manager who was external to the practice to the role of the Freedom to Speak Up Guardian and we saw evidence of a poster which advertised this for staff.

The practice valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. Staff had received training in equality, diversity and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion and disability. There was a zero tolerance to bullying and harassment and leaders were committed to providing an inclusive and supportive working environment.

The vast majority of staff we received questionnaires from, reported high levels of job satisfaction. 92% of staff told us they felt valued and were encouraged to be involved in contributing to the running of the practice.

The practice 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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities.

The practice had established governance processes and 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.

From our review of personnel files however during the onsite visit, we found that not all necessary recruitment documents were accessible in the staff files. For example, most staff files were missing their employment history, interview notes and immunisation records. Not all clinical staff had completed their mandatory training, including sepsis training. We were assured however staff knew what to do in urgent circumstances as procedures were in place and reception staff could communicate with the duty GP for additional support in an emergency. The practice acknowledged our feedback on staff personnel files and training and wanted to improve these processes. Following our onsite visit, the management team made arrangements to ensure all staff completed sepsis training by adding “Sepsis Awareness” training to the staff training profile.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for patients. They shared information and learning with partners and collaborated for improvement. The practice worked with other practices within their primary care network (PCN) and staff told us there were quarterly meetings where practices shared best practice and quality improvement.

Staff were encouraged and supported to attend local forums which provided networking opportunities with other services within the primary care network. For example, staff told us they attended the Herefordshire GP leadership team meetings on a weekly basis. Leaders told us staff also attended regular Practice Management and contracts meetings.

Staff explained they were working to develop a practice patient participation group (PPG) and were exploring ways to attract patient membership and attendance. The practice did however collect patient feedback regularly via the NHS “Friends and Family Test” and reported on these outcomes each month. On an annual basis, the practice reviewed the National GP Patient Survey results and identified areas for improvement.

The practice had a strong focus on continuous learning, innovation and improvement.

Staff participated in quality improvement work and used learning from significant events and complaints to continually improve the service they provided.

Leaders told us about various quality improvement work the practice was engaged with such as investing in Population Health Management (PHM) business intelligence software. This software assists GP practices and primary care networks (PCNs) to use data to understand the health needs of their local population, identify at-risk patients, and design proactive, preventative care.

The practice participated in the national General Practice Improvement Programme (GPIP), which provides support to GP practices to explore and implement opportunities to improve productivity, patient outcomes and staff wellbeing.

In addition, the practice was due to participate in the Neighbourhood Health Implementation Programme (NNHIP), which is piloting new models of primary and community care. The programme is a government initiative to establish neighbourhood health services that shift care from hospitals to local communities.

Since our last assessment, the practice had become part of the Clinical Practice Research Data (CPRD) network and were currently undertaking primary care studies and trials with the West Midlands Primary Care research team.

In addition, from September 2025, the practice was planning to host their first cohort of year 2 medical students for the Three Counties Medical School. Leaders told us one of GPs had been nominated as the lead for this initiative as the Training Programme Director (TPD), to manage this programme and ensure it meets curriculum standards and supports the medical students at the practice.

Staff told us other future improvements to the service included the repurposing of rooms to increase clinical space and an application for funds to convert existing surplus waiting room space into additional clinical rooms.