Balfour 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

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 Inadequate. At this assessment, the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. During our assessment of this key question, we found senior leaders promoted a positive staff culture. Staff reported they felt supported in their roles and could raise concerns openly and transparently. There were clear and effective processes for managing risks, issues and performance. There was a demonstrated commitment to using data and information proactively to drive and support decision making.

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.

The service had a shared vision, strategy and a culture that supported this. The core values of the practice were based on putting patients first with accountability of care. Staff spoke positively about the culture of the practice. Leaders understood the challenges and the needs of patients and their communities.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively and had clear oversight within the practice. They did so with integrity, openness and honesty. Staff spoke positively about the leaders being approachable and compassionate and provided examples of how they had supported them through difficult times.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had a whistleblowing policy in place and there were clear processes for staff to speak up. Posters were in each room with the details of who the external freedom to speak up guardian was and how to contact them.

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 told us there was an inclusive and fair culture and they felt valued.

The practice had clear responsibilities, roles, systems of accountability and governance arrangements were in place. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared 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 clinical and non-clinical staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice 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 was a Caldicott Guardian policy in place which included a named Caldicott Guardian.

The practice engaged with patients, communities and partners to share information and learning. The practice worked well with other practices within their primary care network (PCN) and other organisations to ensure patients received joined-up care. Leaders from the PCN provided positive feedback relating to the participation of the practice in local and national healthcare initiatives.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff gave examples of support they had been given by the practice, including opportunities for learning and development. Leaders gave examples of their own continuous learning to improve outcomes for patients and the wider community. The practice had processes in place to ensure that learning happened when things went wrong. Leaders encouraged staff to speak up with ideas for improvement. We saw evidence that the practice was innovative in their approach to patients' wellbeing and had engaged with the PCN which resulted in positive outcomes for patients’ health. An example of this is the implementation of a phlebotomy clinic within the practice. Patients had raised concerns about the length of time it was taking to get a blood test locally. In response to this, the practice approached the PCN and worked closely with them to enable patients to obtain their blood tests at the practice with minimal wait times. Patients we spoke with were very positive about this improvement.

The practice actively contributed to safe, effective practice and research. They had a quality improvement plan in place to help drive improvements in the take up of childhood immunisation etc services. This involved clinical and non-clinical staff and was reviewed regularly.