Doncaster Same Day 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

We assessed 8 quality statements from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was good. Our rating for this key question remains good. The provider had a clear vision and credible strategy to provide high quality, person-centered care. We found 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. Governance structures and systems were in place which had been refreshed and re-implemented in January 2024. There was evidence of systems and processes for learning and continuous improvement.

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 leadership for the organisation was from an executive board whose membership was made up from representatives from all areas of operation. On the day of inspection the service demonstrated they had the experience, capacity and capability to run the service and ensure high quality care. Leaders understood the challenges and needs of people and their communities, and their delivery approaches reflected this accordingly. They demonstrated a commitment to developing a supportive and open culture for staff which was supported by the positive feedback received from staff about the atmosphere and culture of the service.

Staff at all levels had a well-developed understanding of equality, diversity, and human rights, and they prioritised safe, high-quality, compassionate care. Equality and diversity were actively promoted, and the causes of any workforce inequality were identified, and action was taken to address these. There were arrangements in place to ensure the staff were kept informed and up-to-date. This included staff briefings through newsletters, and emails and opportunity to review the incident reporting outcomes within the incident reporting system.

Staff told us that the management team was easy to contact and that they listened to their staff, whatever the size of the problem. They told us management had an ‘open door’ policy and they could approach leaders at any time if they required support. Staff told us they received regular appraisals and were given opportunities to discuss development and any training needs during their appraisal. All staff had received the training they required for their role and were up to date with their training.

There were policies, processes, and systems to support the governance and management of the service. There were regular meetings during which issues significant to the delivery of clinical care were discussed and reviewed. There was an up-to-date business continuity plan in preparation for major incidents. The service had good oversight of governance arrangements. The service had developed its governance systems to ensure that quality was systematically embedded across the organisation.

Staff knew how to raise concerns about the service, and they felt comfortable and empowered to do so. However, not all staff were aware of the Freedom to Speak Up Guardian.

The provider had a process in place for regularly seeking and responding to staff feedback. We observed the staff notice board that contained key messages and staff updates.

The practice had a diverse workforce in place. Equality and diversity training was part of the mandatory training for staff. We saw examples of how the practice had regular meetings with staff.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with 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. Staff took patient confidentiality and information security seriously.

We did not receive any feedback from members of the public regarding this service. The evidence we reviewed did not show any concerns about assessing and reviewing their health care needs. The provider had arrangements in place to allow patients the opportunity to provide feedback on the service received.

Leaders described and evidenced how they collaborated with a range of relevant stakeholders and agencies. For example, regular engagement with the GP practices who used the service, the Integrated Care Board and Healthwatch. We found staff and leaders were open and transparent.

The practice worked with commissioners. For example, a performance report was competed in May 2024 that included emergency care overall activity and performance by month, staff training performance, medication management performance and clinical guardian audits which scored an average of 90.9% for the last 12 months.

Leaders have begun to develop an improved structure of engagement with people, communities, and partners to share learning and continuous improvement since the introduction of a new management structure and strategy implemented in early January 2024.

Leaders demonstrated, how since the introduction of their new strategy in January 2024 they had improved. Some staff we spoke to commented that significant improvements had been made at the service since the new structure had been implemented. Processes were in place to ensure that learning happened when things went wrong. There was a keen sense of trust and accountability between staff and the leadership team. The provider had been nominated for an award as part of the Integrated Care Initiative of the Year and was awarded this from the Doncaster Wound Care Alliance. There was a focus on continuous learning and improvement at all levels within the service. The service team was forward thinking and part of local pilot schemes to improve outcomes for patients in the area. For example, by engaging in the local health and social care plan and further developing the role of the Emergency Care Practitioner (ECP) in the community.