Church Lane 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

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported by leaders and described a positive workplace culture. Staff understood their roles and responsibilities. While several governance processes were well established, certain areas required review to strengthen oversight and monitoring. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement and leaders actively supported staff in role development and upskilling initiatives.

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. Staff were aware of the practice’s vision and strategy. The provider had plans in place to renovate the premises so they could expand the number of clinical staff and medical teaching sessions they could offer. Staff described a positive workplace culture, highlighting a cohesive team environment and a supportive, family-like team dynamic.

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. There was a high level of staff retention and staff told us leaders in the practice were approachable and responded to any concerns raised. Staff told us they felt supported and were encouraged to develop. For example, a Nurse Associate was being supported to train for her nursing qualification. Leaders had reviewed its workforce, completed succession planning, and actively supported staff in role development and upskilling initiatives. We saw the leadership team worked with other practices in the Primary Care Network (PCN) and were engaged in the development of primary care services within the local area.

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 access to an external Freedom to Speak up Guardian. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They worked 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 and staff had received equality and diversity training.

The service had clearly defined roles, responsibilities, and systems of accountability. While several governance processes were well established, certain areas required review to strengthen oversight and monitoring. For example, improvements were needed in the oversight of task lists, urgent referral pathways, and the management of emergency medicines. Staff were appropriately trained; however, the training matrix did not clearly reflect the training status of all staff members. Systems were in place to monitor patients prescribed high-risk medicines, but these were not always aligned with recommended timeframes outlined in national guidance. Additionally, the standard operating procedure for responding to patient alerts in the clinical system required further review to ensure consistency and effectiveness.

The provider had implemented several effective governance systems. Leaders and managers were supportive of staff, and all staff interviewed demonstrated a clear understanding of their individual roles and responsibilities. Managers held regular meetings with staff to conduct appraisals. Staff had access to all relevant policies and procedures. Practice meetings were held regularly, during which clinical concerns and emerging risks were discussed. Actions arising from these meetings were clearly documented. Staff demonstrated a strong commitment to patient confidentiality and information governance.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider worked with other practices within their PCN, including the shared use of staff such as a First Contact Physiotherapist and a Social Prescriber, both of whom regularly attended the practice. The practice maintained an active Patient Participation Group (PPG) comprising 19 members, with approximately 10 members attending quarterly meetings to provide feedback. For instance, the practice engaged with the PPG on a monthly basis following the initial implementation of the new triage system to address any emerging issues. The practice had consulted with the PPG when planning the renovations to the practice with regard to access for those with disabilities. PPG members had also supported the practice by assisting patients with registering for online services and navigating the NHS app.

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. The practice had recently implemented a quality improvement plan to review and monitor clinical audits to help drive improvements in the service. All staff were encouraged to develop, for example, reception staff were given Care Coordinator roles which they told us they found rewarding being able to actively support patients and signpost to appropriate services. The practice is a training practice for GP Registrars. The provider had received multiple accolades, including the Clinical Improvement Award for Long-Term Conditions at the North Lincolnshire Primary Care Awards 2024, in recognition of their diabetes improvement initiative. Additionally, one of their GPs was honoured as GP of the Year 2024, and their Practice Manager received the Practice Manager of the Year 2024 award at the same event.