The Waterfield Practice

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

Roles and responsibilities for management and leadership were clear and known by all staff. The service monitored performance and where opportunities to improve existed, changes were made. Data was used to help make decisions and monitor progress. Governance systems and processes existed but could be further embedded or improved. This would ensure the service acted on the best information and benefit patients.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance systems and processes existed within the practice. For example, performance and risk was monitored and there were systems to receive feedback and complaints from patients. When new processes were introduced, audits were completed to establish baselines. We were provided an example of an audit completed after an external register of patients that lived alone was shared with the practice. The practice audited their own clinical system to see whether patients’ records were coded with this information and found 3 of the 10 patients sampled were. The remaining patients were identified by free text searches. This identified coding could be improved. The practice had a risk register. There were limited entries but when we spoke with leadership and management, they confirmed these were the risks the practice was monitoring and managing. Leadership explained this system had been changed recently and agreed it could be improved further but we were assured the system was operating within the practice. When risks were identified the practice responded to mitigate or manage them to reduce the risk. For example, a recent Fire Risk Assessment (FRA) completed in June 2023 included recommendations to improve fire safety at both sites. The practice had prioritised the actions within the FRA on a risk basis and had completed many, with those outstanding needing further quotes or contractors to become available to undertake the work. The practice had processes to receive feedback from patients. We discussed the process to make a complaint due to patient feedback reporting they had not found it accessible or simple. The practice explained there were plans to improve this system soon. We sampled a response to a complaint and found it contained a detailed explanation of the investigation undertaken, an apology, and details of how the patient could escalate the complaint if they felt their concern had not been addressed.

We spoke with staff in a range of roles including leadership, management, and support. All were clear about their roles and responsibilities. We also reviewed minutes of meetings for a complete range of staff groups. These demonstrated that staff communicated effectively within the practice and there were established processes to discuss risk, performance, and concerns. Meeting minutes also showed that staff were valued and wellbeing was a priority for the practice. They also demonstrated that the practice wanted to build a strong team to ensure they service delivered high quality care and was sustainable for the future. Staff we spoke with explained how they had been supported when they had taken on new roles and that they felt teams worked well together in the practice.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.