Naseby 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

The Well-led key question has been rated as Good. We looked at 4 quality statements for the key question of Well-led for this assessment: Shared direction and culture, Capable, compassionate and inclusive leaders, Governance, management and sustainability, and Learning, improvement and innovation.

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.

Staff feedback regarding the culture of the practice was positive. Staff told us leaders promoted an approachable and open culture and we observed there were positive relationships between staff and leaders. Staff reported that they felt able to raise concerns without fear of retribution. Staff were aware of the practice’s vision and values, and told us these included providing unrivalled health care, collaboration and patient-centred approach. We observed a poster in the waiting area which detailed the practice vision for patients.

There were systems to ensure compliance with the requirements of the Duty of Candour and leaders described to us an example of where this had been applied. The practice had a Freedom to Speak Up and Whistleblowing policy in place. Arrangements had been made for one of the PPG members to act as a Freedom to Speak Up Guardian for staff.

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 had completed equality and diversity training, and staff told us they felt they were treated equally. Leaders we spoke with were knowledgeable about issues and priorities of their patient demographic and what work was needed to improve patient outcomes.

There were clear lines of responsibility to support capable and inclusive leadership, and leaders had ensured staff were aware of their roles and responsibilities.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff we spoke with were clear about their role and responsibilities. They told us they had access to policies and procedures to support them within their role and attended meetings where discussions about the practice, such as complaints and significant events were discussed. Staff took patient confidentiality and information security seriously.

Although leaders demonstrated that they had established policies and procedures; evidence from our clinical searches of patient records review demonstrated that policies related to medicines management were not always being implemented as intended.

There was a range of practice policies which were accessible to all staff. These were reviewed and updated when necessary. Our review of clinical records however identified that not all policies were being operated effectively. The practice was registered as a data controller with the Information Commissioner’s Office (ICO). The practice had a Business Continuity plan to provide a first response and a framework under which the practice could be managed and continue to operate under exceptional and adverse circumstances.

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.

Staff told us they were provided with adequate training for their roles and were supported by leaders to acquire new skills. Staff received annual appraisals however we found there was limited information documented as part of the appraisal process for individual staff members. As part our assessment, we spoke with staff about clinical supervision and found there were no formal arrangements in place. Leaders explained their improvement plans for the practice which included a building extension, an internal refurbishment, recruitment of staff, and increased capacity to retain PCN staff for more regular and longer hours at the practice.

The practice engaged with the Primary Care Network (PCN) (an approach to strengthening and redesigning primary care to focus on local population needs). We were provided with minutes of practice meetings where complaints and significant events were reviewed, and the learning was shared within the practice. We saw evidence of a number of audits which had been undertaken to drive improvement.