- GP practice
Ling House Medical Centre
Report from 1 July 2024 assessment
Contents
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
Well-led
We assessed all quality statements from this key question. Our rating for this key question is Good. Overall, we found the practice provided a well-led service. There were clear responsibilities, roles and systems of accountability to support good governance and management. Leaders demonstrated that they understood the challenges to quality and sustainability and had taken actions necessary to address them. Staff feedback about leaders was positive and they told us that they felt supported in their roles.
This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.
Staff feedback regarding the culture of the practice was positive. Leaders told us they promoted an approachable, open and transparent culture. Staff were aware of the practice’s vision and values, and some said they were discussed in meetings. Leaders told us there had been a staff away day where practice values had been a focus. Leaders discussed the business plan and strategy and recent challenges which included the merger with another surgery in 2021 and the associated patient list increase, and the completion of the refurbishment of the premises.
The practice had a clear vision and credible strategy to provide high quality sustainable care. The practice told us their vision was to provide the highest quality primary care treatment to their patients in a safe, supportive and inclusive environment, with clinical excellence at the heart of everything they did. This was underpinned by their values of openness, fairness, respect and accountability. We saw their values were displayed in the practice and on the practice’s website. There was a business plan in place which highlighted challenges, strategies for risk mitigation, and future plans for the practice. The practice was responsive and proactive to feedback during the inspection process.
Capable, compassionate and inclusive leaders
Staff told us that managers were visible and approachable and that they felt supported by them. They felt the practice worked well as a team and, although some acknowledged that at times the pressures of primary care could be stressful, they all pulled together. Staff felt there was a commitment and strong ethos to education and training. The practice had an experienced leadership team in place. Leaders we spoke with were knowledgeable about issues and priorities of their patient demographic and what work was needed to drive patient outcomes.
There was a stable clinical leadership team in place following the retirement of several partners over the last couple of years and the incorporation to an organisation in 2022.
Freedom to speak up
Staff told us they knew how to raise concerns and felt comfortable to do so. They were aware of the practice’s freedom to speak up guardian.
There were policies in place for Freedom to Speak Up and Duty of Candour, which were accessible to staff. There was a nominated Freedom to Speak Up Guardian. Concerns could be raised openly and confidentially or anonymously to support any staff members raising concerns. We saw an example where the duty of candour had been applied following an incident.
Workforce equality, diversity and inclusion
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, including opportunities for learning and development.
There were systems and processes in place to support the safety and well-being of staff. This included policies on lone working, bullying and harassment and zero-tolerance. All staff had undertaken equality and diversity training, and reception staff had undertaken conflict resolution training.
Governance, management and sustainability
Staff we spoke with were clear about their role, responsibilities, and how they interact with other staff. They told us they had access to policies and procedures to support them within their role and attended regular meetings where discussions about the practice, such as complaints and significant events were discussed. 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 information governance training. Leaders told us about the ways in which they monitored and mitigated risks. They were aware that they were below national targets for access, childhood immunisation and cervical screening uptake and were working on ways to improve this.
The practice had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. There was an organisational structure in place and nominated clinical and non-clinical leads for key areas whom staff could contact for advice and support. For example, safeguarding of adults and children, incidents, complaints and infection control. Managers held weekly meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. There were processes in place to ensure data management and security. The practice was registered as a data controller with the Information Commissioner’s Office (ICO). There was a business continuity plan in place.
Partnerships and communities
As part of the assessment process, we reviewed patient feedback from the National GP Patient Survey, the NHS Friends and Family Test (FFT) and an internal survey. In addition, we asked the provider to share details of our Give Feedback on Care process with patients. Patients providing feedback for this assessment had no specific views or concerns in this area. At the time of our assessment the practice was in the process of re-establishing a Patient Participation Group (PPG).
We found staff and leaders were open and transparent. 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), internal surveys, complaints and compliments. The practice used social media sites to promote services. Staff told us they could provide feedback through meetings, a suggestion box, annual appraisal and staff surveys.
We spoke with the NHS West Yorkshire Integrated Care Board (ICB) ahead of this assessment. From the feedback we received from them there was no indication of concern in this area. We saw that the practice had attended a quality and contract review meeting with the ICB in April 2024.
The practice engaged actively with their Primary Care Network (PCN) and one of the partners was the clinical director for the PCN. We saw there were regular PCN meetings, and the practice manager attended monthly ICB meetings. At the time of our assessment there was no Patient Participation Group (PPG) as previous members had stepped down from the role. However, we saw evidence that the practice was actively promoting the PPG to encourage patients to join through their website and quarterly practice newsletters.
Learning, improvement and innovation
Leaders told us that the continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff were supported to undertake further training and acquire new skills. Staff told us they were provided with adequate training for their roles and some staff gave examples of how they were encouraged and supported with professional development. We saw that a healthcare assistant had been supported to train to become a nurse associate. As an accredited training practice, leaders told us they were committed to supporting the development of their trainees.
There were systems and processes for learning, continuous improvement and innovation. The practice engaged with the neighbouring practices in local current and future initiatives which included the Primary Care Network (PCN) (an approach to strengthening and redesigning primary care to focus on local population needs). The practice had a comprehensive schedule of clinical audits and quality improvement initiatives, aligned to their patient demographic, to drive patient care. A range of data was collected and reviewed to improve service delivery and drive outcomes for the patient population. For example, we saw reviews of incidents, patient feedback, audits and patient outcomes such as prescribing. The practice had a commitment to education and training and were a training practice for GPs.