Heathfielde Medical Centre

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• 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

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed. This key question is now rated requires improvement.

The service was in breach of legal regulation in relation to Regulation 17: Good Governance

This service scored 50 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They understood the challenges and the needs of people and their communities for whom they provided services to.

The provider was able to discuss with us the challenges and needs of the community. One of the GP partners discussed with us how at times the expectations of people using the service did not always match with the way the service delivered care. This was not due to the provision of care itself but in the timescales of delivery of care. The partner told us that managing the expectation of people using the service (through discussion) was essential to provide a service that delivered good care in a timely manner.

Not all staff told us that they were aware of a shared vision and strategy or a statement of purpose for the service. Some staff members told us that providing good care for people was the vision of the service, whilst other members of staff said that they had not been included in formulating a vision/strategy for the service and therefore could not discuss it.

When we reviewed the training records for four members of staff, we found that equality and diversity training had not been completed by these staff members.

Not all leaders embodied the culture and values of their workforce and organisation due to no definitive uniformly shared values, strategy and culture embedded at the service. Whist leaders did display that they had the skills, knowledge, experience and credibility to lead effectively, they did not always do so with openness and honesty.

Staff described feeling well supported by the service management team but spoke of a lack of consistent support, visibility and promotion of a positive culture by some of the GP partners. These issues were brought to the attention of the GP partners in a meeting held in spring 2025, and the partner responses were evidenced to the assessment team in a set of undated meeting minutes we viewed.

From the assessment team’s discussion with staff and review of meeting minutes, we were not assured that leaders took staff concerns seriously. We reviewed a set of meeting minutes following a request by the reception/administrative team to meet with the GP partners to discuss concerns relating to processes and working relationships within the service. In attendance was the service manager, two administrative staff members, and two GP partners; the senior partner was absent. According to the minutes, one partner exited the meeting prematurely to take a call and did not re-attend. No apology for this absence was documented in the subsequent written response to the meeting minutes from the GP partnersp.

The assessment team’s discussions with members of staff at the service identified a recurring theme of lack of cohesiveness amongst the GP partners themselves. Staff told us that there was varied consistency amongst the partners in terms of when a partner was on site, or if they were undertaking telephone consultations remotely or on site. We were informed that on occasion partners were on site but had not made their presence known to other staff members, until they were seen walking through the service building.

This issue was raised was raised at the above-mentioned meeting. As part of the response from the partners, they stated that they would say hello to staff when their workload allowed as they needed to get straight to work, and that they were not intentionally avoiding staff.

We saw the GP partners and service management worked with other GP services in the primary care network and contributed to the development of primary care services within the local area.

People did not feel they could speak up and that their voice would be heard.

The service had established Freedom to Speak up (FTSU) arrangements internally, however the service had not established FTSU arrangements with other GP services in the primary care network.

There was only one FTSU guardian at the service, which meant that if a member of staff had a concern with the FTSU guardian, there was no clear pathway on how this could be circumvented and concerns documented if the FTSU was away or a conflict of interest occurred.

Staff were aware of how to raise concerns, and the assessment team were told how staff had used the arrangements in place.

The service did not always value diversity in their workforce. They did not always 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, however staff files that we reviewed showed that not all members of staff had completed diversity and equality training.

We noted that some administrative members of staff had variety within their work and had their working week divided up to do different areas of work on different days, but this variation to the working week did not extend to all staff at the service.

Adjustments had not always been made to ensure all staff were valued. We viewed meeting minutes where concerns raised by staff did not appear to be thoroughly investigated by the partners to support staff. We did not see evidence of discussions with staff members to show what adjustments had been made by partners to ensure that staff felt valued and supported in their role within the service.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Whilst managers supported staff, discussions held with staff indicated that this support was inconsistent from most of the GP partners. Staff we spoke with were clear on their individual roles and responsibilities. The assessment team had concerns that the provider could not provide written evidence of on-going monitoring or appraisals of some staff. One GP partner told us that on the day supervision happens between the physicians associate and/or the clinical pharmacist. This occurred with the GP partners through discussion either during a clinical session or at the end of the session. We were told these discussions would be noted within the patient record of the patient that the discussion pertained to, but we were not shown any evidence of this during our remote clinical records review. Similarly, there was no written record of in-house appraisals for these members of staff.

Managers met with staff regularly to complete appraisals and performance reviews for administrative staff. The provider had established governance processes that were appropriate for their service, but the assessment team found that some areas of governance required further work. An example of this (mentioned in the previous paragraph) being lack of formalised appraisals for non-directly (primary network care PCN) employed staff undertaking clinical duties.

We were concerned that because there was not robust governance in place, the service did not have processes that fully allowed them to identify, and risk assess the health, safety and welfare of staff. The flexibility of some of the GP partners working patterns, meant that at times GP’s were on site, but not known to be on site. The current system did not monitor all staff attendance and was therefore not effective. For example, in the event of a fire, with the current process in place, there would be no record which GP partners were on site unless they had been seen by another member of staff.

The assessment team were also informed of an incident where a patient had collapsed in the waiting area of the service towards the end of an afternoon session. Reception staff were able to give first aid to the patient and call for an ambulance, but this was all they were able to do as there were no GPs on site at the time of the incident to give assistance to the patient or further direction to staff. We spoke with the provider about this who informed us that all staff had received life support training and that the system in place for medical emergencies had been followed correctly. The assessment team was not assured that changes had been implemented to service provision following this incident.

The provider held separate clinical management meetings, management meetings and staff meetings. Significant events were not regularly discussed regularly at these meetings. We viewed a combination of clinical, management and administrative/reception staff meeting minutes, and found one discussion relating to a significant event in these meeting minutes. but the minutes did not clearly indicate outcomes, actions or learning opportunities. Staff meetings involved reception and administrative staff as well as the service manager, who attended the other two meetings held at the service. Meeting minutes did not note in depth discussions held at these meetings. and there was no evidence of any learning gained by staff (because of training or actions taken following a complaint) being shared at these meetings. We noted that there were generally no all staff meetings and that responses from the GP partners to queries raised by staff (who did not perform clinical duties), were relayed to staff by the service manager.

The service management was able to discuss with the assessment team how they used information about the service to assist in reviewing the overall performance of the service and to identify potential areas of risk to the service. This information was presented to the GP partners at the monthly management meeting.

The provider had a business continuity plan which we viewed. This was a comprehensive plan which was reviewed by management annually. We noted within the plan that the local Integrated Care Board (ICB) which commissions health provision geographically, was still referred to as the Clinical Commissioning Group (CCG). CCG’s were replaced by ICB’s in 2022.

Staff could access all required policies and procedures, both in hard copy and online. We viewed a selection of six policies and found them to be version controlled and up to date. Staff took patient confidentiality and information security seriously.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service focused on learning and improvement across the organisation and local system.

Leaders told us they supported the development of their staff and encouraged exploring different ways of delivering improved care, experience and outcomes for patients.

The provider kept a log of complaints received and actions taken as a result. However, there was no evidence of discussions with all members of the team regarding any learning gained from complaints received in the meeting minutes we reviewed. Similarly, significant events were not discussed regularly at meetings, therefore missing an opportunity for learning.

The provider undertook clinical audit and quality improvement activities to assist in ongoing improvement of the service.