Tieve Tara 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

Staff told us that leaders were visible and approachable and that they had access to policies and procedures to support them within their role. However, there was evidence of gaps in systems and processes to ensure compliance with requirements to demonstrate good governance. This included effective management of areas including staff training and supervision, and premises health and safety. In addition, there was no business plan in place to outline the practice’s objectives and how they would achieve these. There were systems and processes in place to support the safety and well-being of staff. The practice took part in initiatives to strengthen partnerships and support the local community.

This service scored 62 (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 mostly positive. Staff told us they had not been involved in the planning of the practice’s vision and values but understood what they were and their role in achieving them.

The practice’s vision was to provide 'quality, joined up healthcare with compassion, that is accessible to everyone and supports the whole person.' The practice had identified 2 areas to focus on to achieve this vision, which consisted of ‘compassionately addressing the non-medical needs of patients’ and ‘developing an inclusive and engaging work culture’. The practice provided a brief overview of the strategic ambitions at provider level, however there was no practice level business plan in place to outline how their vision would be achieved.

Most staff told us that managers were visible and approachable and that they felt supported by them. Managers told us how they had an open-door policy to ensure staff had appropriate support when required.

The practice had recently recruited an administrative manager to support the non-clinical team and was in the process of recruiting another salaried GP. Staff had been supported to undertake further training courses, including apprenticeships. Daily huddles were held to share information and to support staff with any issues.

Most staff told us they were aware of the practice’s freedom to speak up guardian, knew how to raise concerns and felt comfortable to do so. Staff were also aware that they could raise concerns via an external organisation. Some staff felt their concerns may not be addressed if they spoke up as they felt that issues that had been raised in the past had not been dealt with appropriately.

Staff had access to policies on duty of candour and freedom to speak up, and information on this was displayed at the practice. Concerns could be raised openly and confidentially or anonymously. We saw examples of candour being applied by staff where mistakes had been made.

Most staff reported a positive culture at the practice, with adequate support and regard for staff wellbeing. We heard examples of how staff had been supported to carry out their role, for example by being able to work flexibly when this had been requested.

There were systems and processes in place to support the safety and well-being of staff. This included policies on dignity at work, lone working and code of conduct. There was also an improving attendance and wellbeing policy which detailed the support available for staff to carry out their role. Staff surveys had been conducted at provider level and therefore consisted of feedback from staff across several services. Due to low response numbers from staff at the practice, it had not been possible to view and follow up on specific responses and feedback from these staff. There was a staff suggestion box at the practice, however we were told that this was not generally used by staff.

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. However, some staff felt they did not have enough clinical supervision for their prescribing. Some staff told us they did not feel that action was taken in response to feedback they provided to the practice. Leaders told us they were aware of the practice’s low performance in cervical screening uptake and were working on ways to improve this, for example with plans to start a Saturday clinic.

There was a meeting structure in place and minutes or recordings available to staff who could not attend. Policies were in place and accessible to staff. Overview and management of staff training was not always effective as at the time of the assessment some staff had not received or were not up to date with required training. Processes to maintain a safe environment were also not effective as there was evidence that urgent actions identified during risk assessments and routine maintenance were not always managed in a timely manner. There was no practice level business plan in place to outline the practice’s objectives and how they would achieve these. Data and notifications were submitted to external organisations as required. The action plan created by the practice to address some of the concerns raised in our previous inspection in July 2023 had not been appropriately actioned as we found that processes for high-risk drug monitoring, actioning of safety alerts, and clinical supervision of non-medical prescribers were not effectively managed.

We reviewed the responses to the NHS Friends and Family Test (FFT) for the last 6 months and saw that each month over 90% of respondents rated their experience of the service as good or very good. Feedback from representatives from the patient participation group was positive regarding their interactions with the practice. They told us they felt listened to by the practice and that their feedback was acted upon.

Staff gave examples of engagement and collaborative working with other services. They told us about the ways in which they supported communities, for example by participating in community events and holding social events at the practice.

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 initiatives to strengthen partnerships and support the local community.

Staff told us they were provided with adequate training and support for their roles and some staff gave examples of how they were supported with professional development.

The practice used clinical audit to monitor and drive improvement. Staff were supported to develop their skills. The practice worked to drive improvement in different clinical areas. For example, they had hosted a diabetes community hub where patients were able to speak with various internal and external clinical and support staff and sign up to the NHS Diabetes Pathway to Remission programme. The practice had taken action to address some of the concerns raised in our previous inspection in July 2023, for example by improving monitoring of patients with long-term conditions. However, we found that processes for high-risk drug monitoring, actioning of safety alerts, and clinical supervision of non-medical prescribers were not effective.