Bellbrooke Surgery

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

Overall, we found that the practice was well-led. Staff told us that leaders were visible and approachable. Staff had access to policies and procedures to support them within their role. Clinical staff attended regular meetings however some non-clinical staff felt they did not have enough meetings, and that information could be shared with them more efficiently if they did. Staff told us they were well supported and there were systems and processes in place to support the safety and well-being of staff. There was evidence of a learning culture within the practice and performance was monitored to drive improvement. The practice took part in projects and initiatives to strengthen partnerships and to gain a better understanding of the needs of their local population.

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.

Staff feedback regarding the culture of the practice was positive. Staff told us they had not been involved in the planning of the practice’s vision, but many told us they had an understanding of the vision and their role in achieving this.

The practice vision was displayed on the practice website. The practice had a clear set of aims and objectives which included being responsive to the needs of patients and providing support to staff. There was a business plan in place, and this covered targets, challenges, and future plans for the practice.

Staff told us that managers were visible and approachable and that they felt supported by them. Leaders were knowledgeable about issues and priorities for the quality of services and what work was needed for these. They felt they had a strong partnership in place.

Leaders carried out succession planning. For example, they provided opportunities for salaried GPs to become partners if they wished to, and supported healthcare assistants in undertaking nursing courses.

Staff we spoke with and received feedback from told us they knew how to raise concerns and felt comfortable to do so. They were aware of the practice’s freedom to speak up guardian.

Staff had access to policies on freedom to speak up and whistleblowing. Concerns could be raised openly and confidentially or anonymously to support any staff members raising concerns. We saw examples of candour being applied by staff where mistakes had been made.

Staff reported a positive and supportive culture at the practice, with adequate support and regard for staff wellbeing. We heard examples of how staff feedback had been used to improve processes, for example making room changes to allow more space in baby clinics.

There were systems and processes in place to support the safety and well-being of staff. This included policies on bullying and harassment, and zero-tolerance. There was also a reasonable adjustments policy for staff which detailed the process for staff to follow if they needed to request adjustments for their roles, and access to occupational health services. There had been no staff survey for over a year. We were told there were plans in place to start using a staff suggestion box for anonymous staff feedback, and that any feedback would be discussed in a team meeting.

Staff we spoke with were clear about their role, responsibilities, and how they interact with other staff. They told us they had access to policies and procedures to support them within their role. Clinical staff told us they attended regular meetings where discussions about the practice, such as complaints and significant events, took place. Some non-clinical staff felt they didn’t have the opportunity to attend many meetings, and that information could be shared with them more efficiently if they did. Some non-clinical staff told us that information on incidents and complaints were shared with them by email whilst others told us they were not aware of them unless they were directly involved. The practice told us they felt that dedicated non-clinical meetings had not been very useful in the past but were reviewing this. Leaders told us about the ways in which they monitored and mitigated risks. They were aware of the practice’s low performance in childhood immunisation and cervical screening uptake and were working on ways to improve this, for example through discussions with different community groups, and delivering education and play sessions at the practice.

There was a meeting structure in place for clinical staff and minutes available to staff who could not attend. Quarterly whole staff meetings were not minuted. Policies were in place and accessible to staff. Data was used to monitor and improve performance, for example data from incoming telephone calls and performance in different clinical areas. There was a business continuity plan in place and this included recovery plans in the event of certain incidents. The practice had processes in place to submit data and notifications to external organisations. We saw examples of how the practice worked with other organisations and the local community to try and improve equity in access and outcomes for patients.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff gave examples of engagement and collaborative working with other services. Leaders told us about the ways in which they supported communities, for example by involvement in family sessions and mental health projects at a local community centre.

As part of the assessment process, we asked the NHS West Yorkshire Integrated Care Board to share their experience of the service. There was no feedback to indicate concern in this area.

The practice worked with and shared information with stakeholders to build a shared view of challenges and of the needs of the population. The practice took part in projects and initiatives to strengthen partnerships and support the local community.

Staff told us they were provided with adequate training for their roles and some staff gave examples of how they were encouraged and supported with professional development. Leaders told us about the ways in which they supported the development of trainees.

There was evidence of a learning culture within the practice. The practice undertook clinical audits and monitored performance to drive improvement. Staff were supported to develop their skills. The practice worked to drive innovation and improvement in different clinical areas, particularly in more challenging areas. For example, employment of a specialist healthcare assistant to support delivery of health checks for patients with serious mental illness and streamlining the process for review of patients with learning disabilities. In addition, the practice had created a women’s health hub to try and reduce the local hospital gynaecology waiting list, and they told us the list had reduced by around 50%.