Spinney Hill 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.

our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 86 (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 culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the local population and was working with partner agencies to address future challenges. All staff within the practice worked with the same vision, to provide patients with the best possible care. Leaders were passionate about supporting patients holistically.

The service had exceptionally 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

The practice had a stable leadership team who each took responsibility for various aspects of the practice. Leaders had a deep understanding of issues, challenges and priorities within the service and worked together with staff to improve these continuously. Although the practice had a stable partnership with eight long term partners, there was clear future planning. Leaders demonstrated high levels of experience, capacity and capability that was needed to deliver excellent care. All practice staff told us leaders in the practice were approachable and responded to any concerns raised. They reported they felt valued for the work that they completed and encouraged to develop through the practice. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network to promote learning and were engaged in the development of primary care services within the local area.

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

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and staff reported they would feel confident in raising concerns.

The service valued diversity in their workforce. They work 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. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example adjustments had been made to support staff with additional needs were in place.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Practice leaders had clear lead areas which was further supported by administrators with lead roles within the practice. This made the governance structure clear to see who was responsible for areas within the practice. All staff were clear on their own individual roles and responsibilities and could describe the overall governance structure. Staff had regular appraisals and performance reviews which were all clearly documented with action plans for development. The provider had established clear and detailed governance processes to ensure there was complete oversight of all aspects of the practice. We saw evidence of audits being completed to ensure that staff were working in line with policies and procedures, where any areas which needed improving were classes as learning events to encourage improvement within the whole practice. The oversight of the practice was strong with very clear documentation to support the systems in place. There were regular practice meetings during which they discussed clinical concerns and emerging risks which was all clearly documented and disseminated to ensure all staff were aware of changes and support for patients. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, vaccination programmes and screening opportunities. Learning events were discussed with the wider primary care network to drive improvement across the local areas. Staff had made adjustments to improve coordination of their service with community healthcare services for patient outcomes.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The practice documented, investigated and shared learning from all events which may encourage learning within the practice. Practice staff were involved in discussions around learning events and encouraged to contribute to provide enhance ideas. When improvement actions were made these were often shared with wider PCN or ICB to promote local improvement. Many clinical templates had been developed following learning events to promote consistency and high-quality care within the practice, with some being utilised by the wider ICB to drive improvement locally. The practice had a quality improvement plan in place to help drive improvements in services. This included both clinical and non-clinical areas of the practice and evidenced improvements which had been made within the service. All staff were encouraged to put forward and test out new ways of working. The practice conducted several audits in relation to work by the practice, such as clinical consultation audits and audits on workflow oversight to ensure that all staff continued to work to high standards. If any shortfalls were found, they were shared with the time as learning rather than creating a blame culture.