Monkwearmouth Health 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 good. At this assessment, the rating remains the same.

This service scored 79 (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 clear and embedded shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and a good understanding of the challenges and the needs of people and their communities. Leaders demonstrated the importance of staff wellbeing to support them in maintaining good outcomes for patients. Leaders invested in learning and development for all staff to assist them in best practice.

There was a clear vision which was followed ‘To strengthen the health of our community by becoming a hub of accessible, comprehensive, and preventative care that empowers people to live healthier, longer lives’.

Values were actively integrated into daily practice, establishing an open and respectful culture. All staff and people felt psychologically safe and empowered to speak up and raise concerns and contribute to help learn and improve. Staff were highly motivated and consistently felt well-supported by leaders. Staff told us they felt valued, motivated, included, and supported because leaders listened and recognised their work. Managers were approachable and promoted open dialogue, invited ideas and addressed areas of concern.

The Primary Care Network (PCN) for the practice was selected as one of the first locations nationally to deliver the National Neighbourhood Health Implementation Programme. This significant initiative aims to deliver healthcare closer to homes through integrated neighbourhood teams, targeting areas with high levels of need and health inequalities. Practice leaders played an active role in both local and national discussions on the programme’s rollout, which seeks to unite GPs, community nurses, hospital specialists, pharmacists, social care, mental health teams, and voluntary-sector providers to offer coordinated, personalised care for individuals with multiple or complex needs.

Leaders had an exceptional understanding of staff and people’s diverse needs and the context in which they delivered care, treatment and support. These were central to their methods of leading an inclusive and highly effective organisation.

Leaders at all levels were highly visible. They embodied the culture and values of their workforce and organisation. They collaborated with people and staff and gained feedback about their leadership style which they used to improve. Staff told us leaders in the practice were approachable and responded quickly to any concerns raised. We were given several examples of changes made in the practice as a result of staff feedback. Staff told us that leaders cared about their wellbeing. For example, they provided facilities to enhance the working environment including an upgraded rest room and new uniforms.

Leaders had insightful and impactful oversight of service quality priorities and risks. There were regular management and staff meetings to ensure all staff members were involved and aware of changes to service delivery as part of the team.

Leaders had high levels of credibility. They consistently did what they said they would and communicated in transparent and accessible ways. Staff told us leaders always acted with integrity, openness and honesty and modelled the values of the practice. 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. Feedback received, both directly by the practice and to the CQC from patients and staff was consistently, highly positive.

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 other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The practice had an open culture where staff felt confident to speak up about any concerns. Staff reported that their views were heard and that they felt safe raising issues without fear of negative repercussions. Leaders encouraged honesty and transparency, creating an environment where staff were comfortable sharing 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. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. Adjustments had been made to ensure all staff were valued, for example adjustments to accommodate flexible working where appropriate, were in place.

The service 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 act on the best information about risk, performance and outcomes, and share 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. Staff we spoke with told us the leaders had an “open-door” policy and were always responsive and available to provide support. Managers met with staff regularly to complete appraisals and performance reviews.

Staff could access all required policies and procedures and understood the importance of patient confidentiality and information security. There were arrangements for identifying, managing, and mitigating risks and a major incident plan was in place. The provider had established governance processes that were appropriate for the service.

Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks, incidents and near misses, patient care and treatment and patient feedback. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

Recruitment processes were effective, with appropriate checks carried out for new staff. Staff were aware of their training requirements, any outstanding mandatory training at the time of the assessment had been completed within a few days.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The Practice was part of the local GP Alliance Additional Roles Reimbursement Scheme (ARRS) providing additional speciality to the service such as pharmacy, social prescribing, mental health and health and wellbeing coaches.

The provider worked with other practices within their Primary Care Network to offer extended access. Leaders coordinated their service with community healthcare services, such as the frailty team in the aligned nursing home. Other examples were through multidisciplinary meetings held regularly with community team.

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 contribute to safe, effective practice and research.

The practice had an established business plan outlining strategies to drive improvements and apply best practices to enhance patient care. Patient feedback was collected monthly through the Friends and Family Test, and the majority of responses were positive. Staff consistently reviewed feedback from patients and the wider community to inform and evaluate new approaches to working. Leaders also considered staff feedback, alongside learning from complaints and incidents, to implement changes and continuously improve the quality of services provided.

Staff were encouraged to propose and test out new ways of working. We observed evidence of a range of audits and quality improvement projects aimed at enhancing performance, outcomes, and patient experience. Examples included clinical audits, pharmacy reviews, comparing prescribing patterns against national data, implementation of a new accounting system providing real-time information for leaders, and participation in an ICB-led programme to improve capacity and access.