Romsey Medical 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

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. This key question has been rated as Good.

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 service vision and strategy, which was kept under review.

The service had inclusive leaders at all levels 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 leaders in the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service.

People did not always know how they could speak up. At the time of the inspection, the provider had not fully implemented formal Freedom to Speak up (FTSU) arrangements, and staff did not have clear information about how to raise concerns externally if required. While staff understood internal escalation routes and stated they felt able to speak up, this gap meant arrangements were not fully embedded. However, following the inspection, the provider sent assurances that FTSU arrangements, including external escalation routes, had been established and communicated to staff.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. Whilst the service had not had to implement any reasonable adjustments for staff, the service had clear systems in place to identify, record and implement reasonable adjustments for people using the service. The service had a current Reasonable Adjustments policy, which set out examples of adjustments, processes for responding to individual needs, and how these were recorded and reviewed, such as adjustments for 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Leaders held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Leaders clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took confidentiality and information security seriously. Monthly governance meetings brought together clinical governance, workforce wellbeing, operational management and compliance monitoring, enabling proactive risk identification, documented mitigation and continuous review. Leadership arrangements remained stable during senior absence through formal delegation and escalation pathways, with no disruption to care or governance systems. Strong safety and clinical governance arrangements were embedded, supported by audits, complaints review, regular clinical meetings and learning. Workforce wellbeing was routinely monitored, statutory and regulatory compliance was planned, and the service had responded proportionately to external healthcare pressures while maintaining operational stability. Such as when the service experienced increased demand following the closure of a local hospital phlebotomy service, which transferred additional workload to the service. Governance systems functioned effectively throughout the period, with no safety incidents and arrangements proportionate to the service’s risk profile.

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 actively engaged in their local community, for example, they had engaged with local community groups to share expertise and encourage open discussion on women’s health. The service had also participated in charitable fundraising events, for example, completing multiple 26‑mile hikes across the UK. The service also delivered community health talks and educational events, such as presentations on gynaecology and nutritional therapy to local audiences in Romsey.

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 service and research. The service’s improvement plan demonstrated a structured and systematic approach to learning and continuous improvement, with leadership oversight from the service’s Clinical Director and Registered Manager. Improvement opportunities were proactively identified via audits, incident and near-miss reporting, significant events, people and staff feedback, policy review, and risk register monitoring. All actions were documented in the service’s ‘Audit Quality Improvement Register’. These actions were tracked through governance meetings, and only closed when evidence showed sustainable, measurable improvement. Learning was used to update policies, enhance training, and reduce risks, while an open culture encouraged reflection and feedback. Themes and learning from improvement activities, such as regulatory updates or annual quality reviews, were shared with staff, ensuring the service adapted to change and maintained resilience. For example, after a significant event or regulatory update, the plan was reviewed and relevant training was enhanced.