Fell Tower 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
At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

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 provider had a shared vision, strategy and culture based on transparency, equality, diversity and inclusion. The practice maintained and regularly reviewed its organisational vision and strategy through a 3-year business planning cycle. Staff understood the practice’s objectives and how these supported the needs of the local population.

Leaders described a positive and supportive culture within the practice. Staff engagement was promoted through regular feedback opportunities, including staff surveys and regular practice meetings. The practice had introduced formal processes to capture, document and respond to staff feedback, supporting continuous improvement and staff wellbeing. For example, QR codes were displayed in various locations throughout the premises, providing staff with an accessible method to submit feedback, suggestions and concerns.
 

The provider had inclusive leadership that understood the context in which they delivered care and embodied the values of the organisation. Leaders had the skills, knowledge and experience to lead effectively and did so with integrity, openness and honesty.
There was a collaborative approach across the GP partners and wider team. Staff were supported to develop their knowledge and skills and were empowered to make decisions appropriate to their roles, with effective oversight arrangements in place.
Leadership was visible and approachable. The practice manager described a supportive working relationship with the GP partners and had access to regular supervision, support and annual appraisal. Processes were in place to gather staff feedback and monitor wellbeing, supporting a culture of openness, transparency and continuous improvement.
 

The provider had arrangements in place to support staff to speak up. Freedom to Speak Up arrangements were established through the Primary Care Network, with staff having access to an independent Freedom to Speak Up Guardian based at another practice. The arrangements were reviewed periodically to ensure they remained fit for purpose. As part of this oversight, regular contact was maintained with the Guardian to promote awareness of the process and support the continued effectiveness of the arrangements.

The provider demonstrated a commitment to diversity, equality and inclusion within its workforce and was working to promote a fair and equitable culture for staff. Policies and procedures relating to equality, diversity and inclusion were in place and accessible to staff, including HR policies available through the organisation's online systems. Leaders described an open and inclusive culture and recruitment processes were designed to promote fairness, including the use of the NHS Jobs anonymised recruitment process, whereby personal identifying information is removed during initial shortlisting. The provider also recognised the needs of staff with caring responsibilities and reported that appropriate support arrangements were available to help them balance work and personal commitments.

Since our previous assessment, the provider had taken action to strengthen governance arrangements and address identified concerns. Oversight of mandatory training had improved through the introduction of a single training platform, supported by a mandatory training protocol, monthly compliance monitoring and protected learning time for staff. Leaders were able to demonstrate improved compliance across mandatory training topics. Formal supervision and appraisal processes had also been introduced, with documented discussions, action plans and follow-up arrangements to support staff development and performance.

The provider had reviewed and strengthened processes relating to capacity assessments and DNACPR decisions. We reviewed 3 DNACPR records initiated by the provider and found no concerns. Employment and personnel systems had also been strengthened through support from an external human resources provider, updated employment contracts and the introduction of electronic staff records accessible through a staff portal. Systems were in place to support staff requiring reasonable adjustments. During our assessment, we identified gaps in proof of identity records for some long-serving staff members. The provider took prompt action to address these gaps. Health declarations had been incorporated into recruitment processes for new starters but had not been obtained for existing staff. Leaders told us they would address this following the assessment. Despite the identified gaps, the provider had made significant progress in strengthening governance and personnel systems since our previous assessment, with a number of improvements already implemented and embedded into practice.

The provider had reviewed how it gathered patient feedback. Although the Patient Participation Group remained small, additional arrangements had been introduced, including an online patient forum to support wider engagement and consultation on service developments, such as planned improvements to the provider's website. Some staff were subscribed to the Disclosure and Barring Service (DBS) Update Service, providing additional assurance that recruitment checks remained up to date.

The provider understood its duty to collaborate and work in partnership to ensure people received coordinated care. The provider worked with other practices within the Primary Care Network to deliver extended access services and support vaccination programmes.

Staff participated in Primary Care Network meetings and worked closely with the Integrated Care Board to support service development and improve outcomes for patients. They also engaged in regular multidisciplinary team meetings with other healthcare professionals to support collaborative care planning and continuity of care.
 

The provider focused on continuous learning, improvement and innovation. The provider had participated in the NHS People Promise GP Pilot, a national initiative aimed at improving staff retention, wellbeing and workplace culture within general practice. Leaders told us the pilot had helped the provider reflect on staff experience and identify opportunities to strengthen staff support, engagement and retention.

The provider demonstrated a commitment to developing services in response to patient and staff feedback. Patients were involved in service improvement through patient surveys and engagement activities. The provider had broadened its approach to patient participation by developing online forums to complement the Patient Participation Group (PPG) and was consulting patients as part of the development of a new practice website. Leaders told us the online platform had improved accessibility and enabled a wider range of patients, including those who worked during the day, to participate and provide feedback on service developments.