Hednesford Medical Practice

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 to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Leaders worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try innovative ideas.

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 in the past had contributed to the development of the practice vision and strategy, which was kept under review. The practice worked with partner agencies to address and consider potential future challenges.

The practice is a GP training practice with an intake of GP trainees every year.

The practice had a considered succession plan in place which was regularly reviewed.

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.

Most staff we spoke with and those we received Care Quality Commission (CQC) feedback questionnaires from, told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders 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.

The CQC had been in receipt of information of concern prior to the assessment which had suggested the practice had not appropriately responded to the issues that had been raised. These concerns with consent, were shared with the Integrated Care Board (ICB), the practice responded and investigated the concerns and took action to support learning and improvement.

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 (PCN). Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect. The CQC received 8 staff feedback questionnaires, and all were positive on culture, leadership, education and support, no issues were highlighted in respect of freedom to speak up avenues except for ensuring contact details for the external Freedom to Speak up guardian were available. We fed this back to the practice who then demonstrated this had been updated on their policy and had included an electronic link.

The service valued diversity in their workforce. They 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. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The practice had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Leaders held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Leaders clearly recorded any actions arising from these meetings and ensured they shared these with staff.

We found that staff took patient confidentiality and information security seriously. However, after our onsite assessment the CQC received information of concern in relation to a governance of paper records event 2 years earlier. Following a discussion with the CQC the provider advised this had been managed at the time and risks of reoccurrence mitigated, including updates in their policies and procedures. However, this had not been documented as a significant event or stakeholders contacted. The provider assured the CQC they would complete a retrospective review of the event, contact the Information Commissioners Office and report the concern to the ICB and any patients affected would be contacted. The outcome and actions once concluded were to be shared to the CQC.

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 provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcareservices, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The practice supported community events for example a memory event, attended by over 150 patients, working with Alzheimer’s UK, the local memory services team, Living Well Service, Support Staffordshire Voluntary Service, Cannock Chase Inspiring Health Lifestyles team. More recently in March 2025, a cancer bus promotion toured various locations around Cannock and Stafford working with the social prescribers to disseminate help and support for early detection, and signposting support for those living with cancer and their carers. In August 2025 at the Hednesford Festival the practice collaborated with Support Staffordshire, Stroke Survivors and Cannock Cancer Awareness Support Group with over 70 attendees to their stall.

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 a quality improvement plan in place to help drive improvements in services.This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working.