Wordsworth 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

The practice had made improvements in the well-led key question following our last inspection in December 2022 to January 2023. Leaders had put together an action plan to work on renewing processes and structures. Leaders had improved their governance and oversight over practice systems, processes and policies.

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.

Leaders stated they had renewed their vision, values and strategy for the practice. Leaders had conducted a staff wellbeing workshop and staff satisfaction survey. The survey found that the majority of staff were satisfied with the leadership and management in the workplace and felt supported by the management team. We spoke to several staff members who told us there was a positive culture within the practice and they felt supported by the management team.

Following our previous inspection the practice had put together an action plan to review systems and processes. The practice had an organisation chart which detailed the chain of management at the practice and all staff members were able to identify the roles and responsibilities of staff. Leaders were able to demonstrate they understood the challenges they faced to quality and sustainability and were working towards overcoming challenges through action plans. We saw a detailed business plan and business continuity plan.

In response to the findings of the previous inspection, the practice invested in recruitment to enhance the management team’s visibility and improve oversight of the practices’ operation. In our previous inspection, leaders could not demonstrate the capacity to prioritise safety and quality improvement as several systems and processes had been found to be unsafe. In this assessment, we found the practice enhanced its oversight of systems and processes, including improved management of, for example, the high-risk medicines and staff training. The practice expanded its team by hiring additional staff, such as the recruitment of a business manager to improve practice policies and their compliance with safety protocols. Staff members we spoke to told us they felt supported by the management team; this was reflected in a staff survey carried out by the practice in which 86% of staff were either very satisfied or satisfied with the overall leadership and management with 91% of staff stating they felt supported by their line manager.

The practice updated their recruitment policy to detail the practices’ processes for the recruitment and selection of staff, with a recruitment checklist in place for prospected members of staff. In the last inspection, we were not assured the practice were following appropriate recruitment procedures; in this assessment, a review of a sample of staff files found the practice were conducting appropriate recruitment checks, such as obtaining references and a DBS.

Staff members we spoke to told us there was an open and honest culture within the practice and that they felt there was an open-door policy. They felt able to raise concerns with the management team and felt listened to when speaking to leaders. Staff were able to identify their Freedom to Speak Up Guardian.

The practice had a whistleblowing policy which included information about arrangements to raise and escalate concerns. The practice had a freedom to speak up guardian for staff to speak to.

Staff members we spoke to told us they felt supported by the management team. Leaders at the practice held a wellbeing workshop which involved an anonymous questions which yielded positive results in relation to staff satisfaction. Staff also told us there were regular social events, which included a trip abroad.

There were systems and processes in place to support workforce equality, diversity and inclusion. We saw the practice had an equality and diversity policy and staff files we reviewed showed a completed record of equality and diversity training.

In our previous inspection, we found structures, processes and systems to support good governance were not effective. We found, for example, concerns around the management of safeguarding, medicine management, recruitment procedures and failsafe systems for two-week referrals. During this assessment, leaders explained improvements were made with more oversight placed on processes and systems. For instance, we examined there to be better oversight on medicine management and recruitment procedures within the practice. Many practice policies were reviewed, such as the safeguarding policy to include more detailed information. Roles and responsibilities were clear, and the practice were able to demonstrate who held oversight on systems and processes.

Leaders ensured there were clear responsibilities, roles and systems of accountability to support good governance and management. The practice held regular practice, clinical and multi-disciplinary meetings, during which performance, risks and feedback was shared with staff. We reviewed minutes from meetings and saw actions arising form meetings were recorded and acted upon. Risk assessments, including fire safety and health safety, were completed. The practice ensured safety checks were routinely carried out.

The practice had an active Patient Participation Group (PPG) who met with the practice management team on a quarterly basis. Twelve patients were registered on their PPG (at the time of the assessment). We spoke to two members of the PPG, who spoke positively about the practice team and stated clinical and non-clinical staff listened to and involved patients.

Leaders told us they collaborated with stakeholders and held meetings engaging with district nursing, palliative care and health visitors. The practice worked on different projects with secondary healthcare providers, such as a workshop to help patients with diabetes in collaboration with a university.

Leaders explained they held multidisciplinary team meetings to discuss and improve outcomes for people with complex needs and regular safeguarding meetings with health visitors to discuss child safeguarding. Leaders explained how they collaborated monthly within their Primary Care Network (PCN) by holding PCN meetings and sharing information.

The practice worked closely with other practices to identify and improve local health inequalities. For example, the practice conducted a 6-week project to tackle inequalities in access to health information for people living with diabetes.

Leaders explained there was a process of continuous learning, improvement and innovation within the practice. This was exemplified in practice meetings in which complaints, significant events and ideas were shared with staff members.

There were systems and processes in place for learning, continuous improvement and innovation. The practice encouraged the upskilling of staff with most recently a receptionist trained to work as a health care assistant. We saw evidence of clinical supervision being carried out to improve consultations. We saw examples of quality improvement projects and innovative methods to engage with patients, such as weekly chair-based exercises with patients.