Sinnott 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

While we found some strengths in the service’s leadership, management, and governance, including a commitment to person-centred care, support for learning and the promotion of an open and fair culture, overall, the service requires improvement in how it is led.Governance processes were in place and staff reported feeling supported by visible and approachable leaders. The provider had systems to manage performance and risks and had taken steps toward service improvement. However, these measures were not consistently effective in ensuring high-quality care or driving sustained improvements, and further work was needed to strengthen leadership and oversight across the service.

This is the first assessment for this service since its registration with CQC. This key question has been rated as requires improvement.

The service was in breach of legal regulations because they did not ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

This service scored 62 (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 based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an understanding of challenges and the needs of people and their communities. Leaders told us they had maintained an open-door policy, and staff feedback was that leaders were approachable. Staff said that if they had any concerns, they had felt safe to raise them and believed they would be listened to. When patients had been affected by things that went wrong, they had received an apology and had been informed of any resulting actions.

The service had inclusive leaders who understood the context in which they delivered care, treatment, and support. Leaders had been visible within the service and had led by example, demonstrating inclusive behaviours to their staff team. In 2024, the service had carried out a wellbeing session followed by a wellbeing survey. There were nine respondents, 56% reported being very satisfied with the session, and 44% had indicated they were satisfied. Staff had expressed a preference for yoga sessions. In response, the provider employed a yoga instructor to deliver weekly sessions.Additionally, the provider facilitated a daily wellbeing exercise session, and staff told us they were regularly treated to lunches.

The service fostered a positive culture where people felt they could speak up and that their voice would be heard. Staff we spoke with felt that leaders were approachable, listened, and acted in response to matters raised. They told us they did not fear repercussions for speaking up.

There were processes in place to encourage staff to speak up. The service had maintained a whistleblowing policy with guidance for staff on how to approach their guardian service if they were not confident raising concerns internally.

The service valued diversity in its workforce. Leaders worked towards an inclusive and fair culture and staff told us they worked well as a team and supported one another.

A review of evidence across all key questions found that the provider did not demonstrate effective oversight. The provider did not demonstrate effective oversight of clinical governance systems to identify, monitor, or manage risks. Failures were evident in the handling of DNACPR decisions and clinical searches, where inconsistencies were present. These concerns were not detected or addressed through the provider’s governance arrangements, including audits and oversight processes.

Although policies and procedures were in place to support a learning culture, this was not consistently reflected in practice. Recruitment records contained gaps, and training provision lacked consistency. These issues were similarly missed during routine governance checks, further highlighting the ineffectiveness of systems intended to identify and mitigate risks.

These failures raised concerns about the provider’s oversight of staff suitability and safeguarding compliance. Collectively, they demonstrated an absence of robust systems to assess, monitor, and mitigate risks, and reflected a failure to maintain accurate and contemporaneous records . These systemic issues demonstrated a lack of good governance, resulting in a breach of Regulation 17 of the Health and Social Care Act 2008.

The service had defined clear responsibilities, roles, systems of accountability, and governance. Although staff had reported that leaders were approachable and responsive to concerns, further work was needed to ensure that leadership consistently drove quality improvement and embedded learning across the service. Leaders and managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Any actions arising from these meetings was clearly recorded and shared with staff. The service used technology to continually monitor performance, manage health conditions, and support access to the service. Leaders had explained that they used this information to continually assess whether they had sufficient skilled staff to provide a safe service. The service had a business continuity policy in place. Leaders and managers supported staff, and all staff we spoke with had been clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff had access to all required policies and procedures.

The service demonstrated an understanding of its duty to collaborate and work in partnership; however, these efforts had not consistently translated into improved outcomes for patients. Performance in cervical cancer screening and childhood immunisations was below national targets, and we saw no evidence of proactive engagement with the community beyond the standard recall process. This was despite the service recognising that individuals from certain cultural backgrounds may be more reticent to attend cervical cancer screening or immunisation appointments.

Although the service demonstrated collaborative working with individuals and healthcare partners to establish and maintain safe systems of care, there were concerns regarding the timeliness of information sharing. Feedback from the integrated care board indicated that the service did not consistently provide required information in a timely manner, and on several occasions, follow-up was necessary to obtain the relevant data.The provider attributed some delays to outdated contact details following a management change, which highlights a breakdown in a fundamental communication process.This suggested a need to strengthen communication and reporting processes to ensure external stakeholders are kept appropriately informed.

We observed evidence of shared learning and staff involvement at all levels. Leaders had regularly reviewed the service’s assurance systems. Clinical audits and quality improvement processes have been implemented and had contributed positively to service delivery, although they have not yet demonstrated a significant improvement in patient outcomes.

The leadership team had managed clinical supervision and documented all supervision meetings. The provider had a small patient participation group and were taking steps to increase participation. Feedback had been positive, and we were told the group had felt involved and listened to. They met regularly and had been able to submit ideas. The leadership team had introduced some quality improvement initiatives, particularly around the appointment system, and staff were encouraged to contribute ideas. However, we did not see evidence of strong external relationships that support innovation.