Clay Cross 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. This key question has been rated as requires improvement.

This service scored 57 (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 did not have a clear shared vision. The provider told us that their vision was ‘To improve the health, well-being and lives of those we care for’. However, most staff we received feedback from were not aware of this vision and told us they had not been involved in developing it.

Staff were mostly positive about the culture within the practice and described it as open and transparent and that leaders listened to them though did not always act on their concerns. Leaders were aware of gaps in staffing groups and had plans in place to address them.

Leaders were inclusive and staff told us leaders in the practice were approachable and listened to any concerns raised. They did so with integrity, openness and honesty. Leaders had some understanding of the context in which the service delivered care, treatment and support.

However, leaders did not always have the skills, knowledge and experience to lead effectively. For example, lack of sharing of learning from significant events and complaints, lack of clinical audits, failure to complete risk assessments to mitigate potential risks and governance structures which were not always reviewed in a timely manner. Leaders told us they were eager to learn and open to suggestions of support.

The service fostered a positive culture where people felt they could speak up and their voice would be listened to. They had established Freedom to Speak up arrangements within the practice and staff were aware of who to go to support.

External Freedom to Speak up arrangements were not in place, for example with other practices in the primary care network. This meant that staff did not have external support to speak up if they did not feel able to approach the internal Freedom to Speak up guardian.

The service valued diversity in the 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.

The service had clear responsibilities, roles and systems of accountability in place. They used these to manage and deliver care, treatment and support.

However, risk assessments had not always been completed where required. For example, storage of oxygen; fire; legionella; gas safety at the branch practice; risks to staff whose full immunisation history had not been assessed and lack of suction and pain relief within the practice.

A system of regular review of policies was not in place. From the policies we reviewed, we found that most had not been reviewed since 2022 or 2023 and they were not always up to date. For example, the complaints policy referred to previous practice managers and sign posted people to NHS England. This changed to the Integrated Care Board (ICB) in July 2023. The safeguarding policy did not include the correct level of training for staff and the significant events policy referred to Clinical Commissioning Groups which were replaced by ICBs in July 2022.

Meetings for clinical staff, safeguarding, palliative care and people with frailty were held on a regular basis to support communication, staff and patient safety. However, staff told us that regular administrative team meetings were not held. We asked for the minutes from the latest team meeting and saw that they were dated June 2023 and June 2024.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement for example, with the Primary Care Network (PCN) and the Patient Participation Group (PPG). Staff were encouraged and supported to attend local forums which provided networking opportunities with other services within the primary care networks. These included monthly practice manager and practice nurse forums. Staff were given protected time to attend these meetings.

The practice had a PPG that met 3 monthly. Their aim was to work with the practice to improve services for people. The practice manager always attended these meetings. A representative from the PPG told us that their views were listened to and acted on where possible.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. For example, the provider forwarded 4 audits to us which were just searches. They showed the number of people prescribed medicines that were in short supply of had been discontinued. There was no evidence of learning in them or second cycles to monitor that changes made were effective. Staff told us that learning from significant events and complaints was not always shared with staff.

There were innovative examples of how the practice provided care and support to vulnerable groups of people. For example, a regular carer’s café and support pack which sign posted people to appropriate support agencies.