- GP practice
Bridgemary Medical Centre
Report from 11 November 2024 assessment
Contents
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
Well-led
We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. We reviewed five quality statements.
At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.
We found breaches of regulation in relation to medicines management and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.
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.
The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.
Capable, compassionate and inclusive leaders
Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.
There was scope for leaders to improve oversight of medicines management processes. The practice had an external consultancy organisation working with them to support improvements to patient care and internal processes.
Freedom to speak up
The service fostered a positive culture where people felt they could speak up and their voice would be heard.
The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.
Workforce equality, diversity and inclusion
The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.
Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.
Governance, management and sustainability
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. There was a strong focus on improving governance within the organisation.
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.
However, we found that there was a lack of oversight relating to medicines governance, especially relating to high risk medicines which required monitoring.
Partnerships and communities
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.
Learning, improvement and innovation
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.