The Belgrave 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. At our last assessment in July 2023, we rated this key question as inadequate. At this assessment, the rating has changed from inadequate to good because we found the issues related to poor governance, leadership, and management at the last assessment had been followed up on and the risks mitigated.

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. The practice had a team of experienced well qualified team members who had agreed to present their business case to the integrated care board on building renovation to improve the quality of care for the patient population. Some of the salaried GPs had taken on more responsibilities to improve care delivery. However, some of the staff we spoke to could not tell us the vision of the practice but were aware of the direction to which it was headed. The practice operated a no- blame culture and staff told us that there was good leadership and staff were supportive.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us that the leaders were approachable, modelled the values of the practice and responded to any concerns raised. The service worked with other services within the primary care network.

The service fostered a positive culture where people felt they could speak up and their voices would be heard. The service had established Freedom to Speak up arrangements with the local primary care network. Staff were aware of how to raise concerns internally and externally. Staff knew that the leaders were open and could be approached with any of their concerns.

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.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Staff we spoke to were clear on their individual roles and responsibilities. However, we found a clinical staff member who had not completed the required yearly training. We were informed that the management had asked the identified staff prior to the CQC site visit, which indicated that the system and processes to monitor staff training were not effective enough. Leaders had oversight of all clinical and administrative tasks. Staff could access all required policies and procedures. However, there were policies that were not specific to the practice; for example, the adult safeguarding policy but this was updated after our feedback. There were regular practice meetings, during which clinical concerns and emerging risks were discussed. The meeting minutes were not always clearly recorded including any actions arising from the meetings and shared with staff. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service engaged with the patient population, including the patient participation group (PPG) to improve service delivery in conjunction with community health services and the primary care network. The practice worked with the primary care network (PCN) nurses on how to improve the uptake of health screening and childhood immunisation.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The service was proactive in improving the quality of the service received by the patient population through audits of system and clinical audits. Feedback provided to the service during the assessment process were followed promptly with evidence to support the actions completed. The practice operated a family practice ethos and the doctors at this location had been there for a long time and were aware of the needs of the patient population and how to improve the quality of care.