Hendford Lodge 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 assessed all quality statements in the well-led key question.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good. We found that the provider had clear and effective governance processes, which supported the safe delivery of care. Staff were clear on their individual responsibilities and knew who was accountable for each aspect of the service. The practice encouraged candour, openness and honesty.

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 practice had a shared vision and culture which drove high quality sustainable care.

The vision statement was displayed in the practice and staff were aware of it. Staff commented that the culture was very friendly, and staff were supportive of each other. There was good teamwork and staff enjoyed working at the practice. There was an emphasis on the safety and wellbeing of staff. The practice encouraged candour, openness and honesty. There were arrangements to deal with any behaviour inconsistent with the vision and values.

Staff were encouraged to attend monthly staff meetings during which updates, and new information was shared. Minutes of the meeting were recorded and accessible to all staff on the practice electronic system.

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.

We received positive comments from staff regarding the support provided by team leaders.The leaders were visible and approachable and responded to any concerns raised. Leaders recognised the importance of staff wellbeing and helped to coordinate flexible working so people could achieve a good work-life balance. Leaders were aware of the challenges of delivering good quality care and were striving for improvements.We received many examples of how the practice implemented changes in response to staff feedback. Changes in the practice were communicated through team meetings and emails. However, a few staff members wished for better communication regarding changes that affected their roles.

The service fostered a positive culture where staff felt they could speak up and their voice would be heard.

Staff felt confident to raise any concerns with their managers and leaders. The practice had a whistleblowing policy which clearly laid out the process of raising concerns within the practice and externally. Staff could name the Freedom to Speak Up Guardian (a person who supports workers to speak upwhen they feel that they are unable to do so by other routes).

The service valued diversity in its workforce.

All staff had completed training in equality and diversity. The practice had policies on equality and diversity and anti-bullying and harassment. Staff we spoke to told us they had not experienced discrimination or discriminatory behaviour whilst working at the practice. Staff gave examples of how the practice made reasonable adjustments to support their family circumstances and health needs.

Staff and leaders were clear on their individual roles and responsibilities. Staff took patient confidentiality and information security seriously. Managers met with staff regularly to complete appraisals and performance reviews. Staff told us that learning and development opportunities were identified during annual appraisals and appropriate training was sourced. The provider had established governance processes which were appropriate for their service. There was a system to monitor the completion of mandatory training and evidence showed that staff training was up-to-date. 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 which arose from these meetings and ensured the information was shared with staff. The practice had a business continuity plan which provided guidance and information for staff to follow in the event of systematic failures. The provider had oversight of contracts with external providers and liaised with them regarding any issues or changes required. However, we identified shortfalls in the oversight of the review and monitoring of patients prescribed certain medicines in the clinical searches. Following the assessment, the practice took immediate action to review all the patients and manage them appropriately within a reasonable timeframe. The practice developed a new protocol and implemented new processes to monitor these specific patient groups regularly. These processes needed to be embedded to ensure people were not exposed to the identified risks in the future.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

An active PPG represented the views of people using the service. A representative from the PPG provided positive feedback regarding the practice’s engagement with the PPG and provided examples of how service improvement was made based on the patient’s feedback. The practice worked well with the local ICB. The ICB provided various examples of how the practice engaged in quality improvement work to improve people’s experience. The practice worked collaboratively with their local PCN to provide a vaccination service and care home service. The provider worked with other practices within their PCN to offer extended hours of patient appointment.

The service focused on continuous learning, innovation and improvement across the organisation and local system.

Some staff had developed their skill set while at the practice to enable them to take on new roles and responsibilities. Learning needs were discussed in team meetings and individual needs were identified in annual appraisals. The practice supported staff in continuous professional development with funding and protected time. For example, at the time of our assessment, there were staff completing the following qualifications: a Masters apprenticeship programme in advanced clinical practice, a nursing apprenticeship, a business administration apprenticeship and a prescribing course for non-medical staff. The practice was a teaching practice for GP registrars.

Leaders encouraged staff to speak up with ideas for improvement. We saw examples of improvements following staff feedback. The practice was proactive in making improvements to deliver a safe and effective service. The practice had started a project to enable access for care home staff to order medications on behalf of their residents through a secure online system. This was arranged and coordinated by the newly employed pharmacy technician in the practice. The feedback from the care home was very positive, as the new medicine ordering process made it easier and more efficient with faster processing. The care home could also track progress online without needing to call the practice. The practice planned to set up the system with the other care homes that they worked with.