Trinity 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 have rated the practice as outstanding for providing a well-led service as leaders had an inspiring shared approach and strove to deliver and motivate staff to succeed. There was a well-established and effective positive learning and improvement culture. The vision and strategy were co-produced with staff, stakeholders and those who used the service. Governance and management systems enabled leaders to identify information about risks, performance and outcomes. Leaders were visible, knowledgeable and supportive and helped staff develop in their roles. There were high levels of staff satisfaction. Staff were proud to work for the practice and spoke highly of its culture. There was strong collaboration between staff, stakeholders and the local community with a common focus on improving the quality of care and people’s experiences.

This service scored 93 (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 very clear shared vision, strategy and culture. This was based on candour, respect, innovation, safety, being a pro-active service, and remaining patient focused. They told us their vision was to be a pillar of excellence in healthcare, driven and underpinned by their values of passion, integrity, diversity and continuous improvement. Staff told us they had contributed to the development of the practice vision and values, and that they were referenced as part of their personal development through one-to-ones and appraisals. Several staff we spoke with shared how they lived and demonstrated their values in their day-to-day-roles and how they were supported to learn new skills. Staff spoke highly of the positive culture within the practice. They felt they were able to feedback to the leadership team and their voice would be heard.

We saw evidence of strategic planning in the form of meeting minutes and action plans developed by the practice. The partnership had regular partnership development away days to foster strategic alignment, set future goals for practice development and monitor actions and progress. Leaders also told us about future plans for the practice, and the work that had already been done in the planning of this strategy, this included the current major refurbishment of the main practice surgery and upgrading of the branch surgery premises.

Patients, partners and stakeholders were well-informed and collaborative in achieving the strategic objectives. Members of the patient participation group (PPG) told us there was good engagement with the practice and they felt valued and included in practice development. We saw that engagement with the PPG had informed key developments in digital access, wellbeing promotion, clinical service delivery, and communication strategies.

The practice had exceptionally 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 service. The practice was made up of a stable clinical leadership team consisting of 10 GP partners, a GP associate partner and 2 non-clinical partners. There was a clear pathway for GPs wanting to progress to partnership and 2 non-clinical senior managers had recently been made partners. The leadership team understood both the local and national challenges to healthcare and demonstrated they had the skills, knowledge and experience to lead effectively. They had an inspiring shared approach and strove to deliver and motivate staff to succeed.

As part of this assessment, we interviewed 10 members of staff and received 27 feedback questionnaires. The feedback was overwhelmingly positive, in particular regarding the visibility and approachability of managers and how staff felt supported by them. Staff told us the practice worked well as a team and although the practice was currently undergoing major refurbishment at their main site, which meant displacement of some staff to other locations and more crowded work environment, this had been managed well, and they were looking forward to its completion and the extra patient and staff facilities it would create.

Several staff told us how they had been supported with training to upskill from non-clinical to clinical roles and advance in their clinical roles. The practice told us they had a strong commitment to investing in staff to build consistency and loyalty. Staff were complimentary about how they felt the practice considered their wellness. Some staff gave examples of how they felt leaders had been supportive and compassionate both personally and professionally.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. There were policies in place for Freedom to Speak Up and Duty of Candour. There was a nominated Freedom to Speak Up Guardian and all staff knew who this was. Staff also had access to an external Freedom to Speak Up Guardian. We saw an example where the duty of candour had been applied following an incident.

Policies and procedures to promote diversity and equality were in place and staff had undertaken equality and diversity training. Staff reported a positive and fair culture at the practice, with adequate support and regard for staff wellbeing. Some staff gave examples of support they had been given by the practice, both personal and professional. There were systems and processes in place to support the safety and well-being of staff. This included policies and training on lone working, zero tolerance and bullying and harassment.

There was a strong emphasis on governance within the practice, and leaders were knowledgeable about issues and priorities relating to the quality and future of the service. There was an open and embedded culture in respect of patient safety and the practice used every opportunity to learn from incidents and events. They demonstrated a clear and shared vision and focus to strive to deliver the highest quality person-centred care. This included detailed understanding and oversight of risks and actions to mitigate and minimise them. We found there were effective systems and processes in place for managing safeguarding, medical emergencies, premises and equipment, recruitment, staff development, infection prevention and control and medicines management.

There were clear and effective management and accountability arrangements underpinned by a clear organisational structure. The leadership team included a practice manager, business manager, operations manager, central services manager, facilities manager and reception manager who provided collective leadership and support to the wider team. This included a daily duty manager system. There were nominated clinical and non-clinical leads for key areas whom staff could contact for advice and support. For example, safeguarding, incidents, complaints and infection control. Staff told us they understood their role and responsibilities within the structure.

There was a strong framework of accountability to monitor performance and risk. The practice used digital technology and dashboards for clinical, administrative and human resource functions which were aligned to their meeting structure to map, track and monitor all practice activities, decision-making objectives and risks. They felt this promoted accountability and enabled structured tracking of progress.

Clinical performance data was monitored and routinely discussed and reviewed at meetings to identify opportunities for improvement. This included monthly review of clinical searches, quality and performance dashboards and the Quality and Outcome Framework (QoF). An audit programme was in place to monitor performance and promote quality improvement.

There were robust arrangements for the availability, integrity, and confidentiality of data, records, and data management systems. The practice was registered as a data controller with the Information Commissioner’s Office (ICO). Staff took patient confidentiality and information security seriously. Staff we spoke with told us they followed the practice’s confidentiality policy when discussing patients’ treatments.

This was to ensure that confidential information was kept private, for example, patient information was never on view and personal smart cards were removed when not in use. We saw that all staff had undertaken data security awareness training.

There was a business continuity plan in place, which we saw had recently been updated when new staff commenced at the practice.

The practice was extremely responsive to feedback from the assessment and remote clinical notes review and acted immediately upon our findings, including those patients we had highlighted for follow-up.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The practice collaborated closely with the integrated care board (ICB) and practices across the district. Several of the GP partners actively contributed to shaping local healthcare strategies and healthcare accessibility in their roles as clinical director for the federation and the primary care network (PCN).

The practice fully utilised all health resources available to them, both internally and externally, to ensure the most appropriate care and support for their patient population. The practice had been early adopters of the total triage principle in 2021 and had refined this model to its current system. Evidence reviewed demonstrated the provider understood their local population and worked with other local services to support patients in the most appropriate way. For example, the practice utilised their care coordinators and health and wellbeing team in partnership with the PCN, to engage with local communities that traditionally face poorer health outcomes. This engagement included ‘pop-up’ clinics in local mosques, outreach visits to a traveller site and accommodation which housed those seeking asylum. We reviewed some case studies which demonstrated an improvement to quality of health and life as a result of this engagement work. The practice planned to expand their outreach engagement and support, by engaging with local initiatives and charities to reach and support homeless and vulnerable individuals in the city.

Leaders told us they used a range of methods to gather patient feedback. For example, from the National GP Patient Survey, Friends and Family Test (FFT), complaints and compliments. We saw that the practice posted the monthly FFT outcomes on their website. We saw from data collected for the period April 2024 to April 2025, of which there were 5,860 responses, that 86% of patients found the practice to be very good or good. The practice also received individual feedback and compliments was shared with staff members and we saw for the month of April 2025 that 16 members of staff had received positive feedback which included comments that they were respectful, kind, very informative, welcoming, pleasant, efficient, professional and supportive.

The practice had an active Patient Participation Group (PPG) which was established in approximately 2016 and met quarterly. There was also a sub-PPG group who met in between the formal quarterly meetings to facilitate more regular communication with the practice. Comprehensive minutes were maintained of the meetings and available on the practice’s website. We saw the practice were actively trying to recruit new members to the PPG and there was the ability to register interest on the practice website. We received feedback from 3 members who told us that meetings were attended by a GP partner, the practice manager and operations manager and other invited members of the team. We saw that the practice’s health and wellbeing coach had attended a recent meeting to discuss their role, and the support offered to patients. They told us the practice was receptive and responsive, and their feedback was listened to and acted upon. For example, the practice had provided some high seat chairs and had reinstated an earwax removal service at the practice following feedback.

The service had a strong focus on continuous learning, innovation and improvement. They always encouraged creative ways of delivering equality of experience, outcomes and quality of life for people. We saw evidence of proactive engagement through outreach initiatives in the community which resulted in positive outcomes for some patients who face health inequalities.

The practice had a schedule of clinical audits and quality improvement initiatives. A range of data was collected and reviewed to improve service delivery and drive outcomes for the patient population.

Staff told us they were supported to undertake further training and acquire new skills. For example, as a result of patient feedback, we saw the practice had procured equipment and trained staff to deliver a microsuction earwax service.

The practice fostered a wide range of external networks, including by participating in research, which were used to identify and share improvements and innovations. Over the last 3 years the practice had participated in 11 studies and implemented and integrated protocols for the management of patients with diabetes and cardiovascular disease.

The practice took pride in its role as a training and teaching practice and supported GP registrars, foundation year doctors, medical students and student nurses. The practice participated in the GP fellowship scheme to foster development of newly qualified GPs to succeed in their areas of interest. We saw one of the salaried GPs was currently undertaking the Diploma in Child Health.