Creech 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

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

This is the first inspection for this service since its registration with CQC. We assessed all the quality statements in the safe key question. This key question has been rated as good.

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 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.

The service was aware of the projected change in the local population and was working with partner agencies to address future challenges and demands on the service.

There was an open-door policy where staff felt confident to speak up and felt they would be listened to. Staff were supported to identify learning and development opportunities to further their professional development and benefit its population.

Staff spoke positively about the daily huddle meetings where changes were communicated, important messages were shared and issues such as safeguarding concerns could be raised.

The service had inclusive leaders at all levels who demonstrated a clear understanding of the context in which care, treatment and support was delivered. They embodied the values and culture of the workforce and organisation. Leaders had the necessary skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders were approachable and responsive to any concern. Leaders demonstrated the organisation’s values in their actions. The leadership team worked with other services in the primary care network (PCN) (a group of local GP practices working together with community, mental health, social care, and voluntary services to provide coordinated health care) and under the same provider to engage in the development of primary care services within the local area.

The service promoted an open and positive culture where staff felt confident to raise concerns and trusted their voice would be heard. Staff had access to policies and procedures and were aware of how to raise concerns.

Freedom to Speak Up arrangements were established both internally and external, and staff felt assured their concerns would be taken seriously.

The service demonstrated a commitment to workforce diversity and actively promoted an inclusive and equitable culture. Policies and procedures to promote diversity and equality were established and staff had completed training the service deemed as mandatory.

Staff were able to explain their understanding of equality, diversity and inclusion and had completed training.

Adjustments had been made to ensure all staff were valued. Staff gave examples of reasonable adjustments the service had made to support them both at work and in personal circumstances.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals. The service had established appropriate governance processes. Staff could access all required policies and procedures.

The service had a risk register where they had identified potential risks to the delivery of the service and developed actions to mitigate such risks. For example, they had already identified issues around staffing which had affected the backlog of people’s records that required summarising.

Staff were encouraged to attend daily huddles and regular meetings during which clinical concerns and emerging risks were discussed. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

Staff took confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service worked with other services within their primary care network to offer extended access. Staff had improved coordination of their service with community healthcare services. For example, staff met with nurses from a local hospice monthly to discuss people that may be approaching the end of their life to ensure their care was planned in a joined-up approach.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encourage creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice. As a training practice, GP registrars were part of the staff team and were supported with clinical supervision and professional development.

The service had a clear plan for quality improvement to ensure continuous development. The service had an audit plan to help drive improvements in services. For example, a recent project reviewed the follow-up of people that had experienced an acute exacerbation of asthma. Over a 3-month period, the service increased their follow-up rate from 26% to 91% by implementing consistent follow up arrangements, standardising the process for booking follow-ups and ensuring staff were aware of their responsibilities.

Staff were supported with continuous professional development and were encouraged to share new ways of working with the whole team.

The service was participating in a trial of a single-use, environmentally friendly urine collection container. The purpose of the trial was to simplify and improve the cleanliness of collecting urine samples and transferring them into sample tubes, while providing people with a biodegradable receptacle to use.