Delapre 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 the quality statements for this key question. Our rating for this key question has improved from inadequate to good. The practice had responded promptly following the previous inspection in July 2024 to make improvements. Action plans were in place and all staff were involved. Governance arrangements were improved and there was evidence of continuous learning and improvement.

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 and leaders felt there was a clear vision for the future of the practice. Leaders and staff could demonstrate positive changes the practice had made. Staff reported there was an open and honest culture within the practice and they felt able to raise concerns without fear of retribution. However, some staff feedback reported there could be better communication with senior leaders. When patients were affected by things that went wrong, they were given an apology and informed of any resulting action. There was an emphasis on the safety and well-being of staff. We were informed succession planning was in place to maintain the practice as senior members of staff and GP partners approached retirement.

The practice had a mission statement to provide best possible care at all times. They had developed a 5 year business plan which was discussed at managers meetings.

Feedback from staff was positive about the team work they had and how they felt supported by their immediate managers. They felt there was a good ethos of being there to help patients. There was some feedback that more senior managers and GPs could be more visible and supportive and improve communication channels. They felt more appointments and possibly more clinical staff were needed to meet the demand of patients. We found the oversight of governance procedures and knowing when actions had been completed was not always known by the senior management team. We acknowledged during the assessment that the practice was moving internal information to a new management system which may have impacted on this.

Staff had clear roles and responsibilities and were flexible in these roles in order to meet the needs of patients. They were supported with annual appraisals and training to meet the needs of their roles.

Staff told us there was an open and honest culture within the practice and they felt able to raise concerns with the management team and leaders. They told us they had access to a Freedom to Speak Up Guardian, they knew who to contact and would, should they wish to raise any concerns. Leaders advised staff had access to an employee assistance programme for additional support with their general wellbeing and mental health.

There was a Whistleblowing (Freedom to Speak Up) policy that was available for staff in the event they wished to raise concerns. The policy contained links to external organisations for support. Managers held regular practice meetings with staff, where they could share their views.

We were informed the practice had a diverse workforce that reflected their patient population. Staff with protected characteristics were identified for additional support and workplace adjustments as required.

There were systems and processes to ensure there were clear responsibilities, roles and accountability structures to support the workforce, this included human resource support. The systems provided as emphasis on the safety and well-being of staff. Staff and leaders had undertaken equality and diversity training.

Leaders and managers supported staff, and staff were clear on their individual roles and responsibilities. Staff told us they received regular clinical supervision and annual appraisals. They said they attended meetings which were held regularly and they were able to access minutes recorded on the shared drive if they were unable to attend. Different staff members had lead roles, for example, safeguarding and infection prevention and control. Staff were aware of these lead roles and who to approach for support.

There were a variety of policies and procedures in place to support good governance, management and sustainability. These had been reviewed and updated following the previous inspection in July 2023. There was 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. There were job descriptions in place for all staff. There was an action plan developed following the previous inspection that was overseen by a designated GP partner and discussed at weekly management meetings.

We found staff and leaders were open and transparent, and they told us they collaborated with all relevant external stakeholders and agencies. The practice held regular meetings with multidisciplinary community teams. Leaders from the practice were actively involved with the Primary Care Network and the local GP Federation. Feedback from patients was sought through local surveys, the NHS Friends and Family Test and the practice Patient Participation Group (PPG).

The practice had maintained relationships with the local commissioners and other support organisations. Northamptonshire Integrated Care Board had worked with the practice to help make improvements. The PPG were positive about the practice, they informed us they felt listened to and kept up to date with changes that were made.

The practice was able to demonstrate effective working relationships with its Primary Care Network (PCN) particularly the use of additional staff through the additional roles reimbursement scheme (ARRS) to improve access to care for patients. There were regular meetings with partner organisations, such as care homes and local leads for safeguarding to ensure safe and effective service delivery for vulnerable patients.

Leaders and managers told us how they had made improvements since the previous inspection and how this had positively impacted the staff and the services they provided. There was a learning culture in the practice which staff and leaders actively participated in.

There were systems and processes for learning, continuous improvement and innovation. We saw evidence of effective supervision, appraisal and training including support given to staff There was an action plan in place to make improvements. Policies and procedures had been updated and necessary risk assessments had taken place. The practice was a training practice and hosted GP registrars (registrars are qualified doctors training to be GPs).