Croft Hall 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 have rated the practice as Inadequate for providing well-led services because:

Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.

The practice culture did not effectively support high quality sustainable care.

The overall governance arrangements were ineffective.

The practice did not have clear and effective processes for managing risks, issues and performance.

The practice did not always act on appropriate and accurate information.

We saw limited evidence of systems and processes for learning, continuous improvement and innovation.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

There was a lack of visible leadership and oversight of governance systems and processes. Staff had mixed views on the visibility of leaders. Managers who were based in the practice were accessible and staff reported they were able to speak with them. However, comments made on staff questionnaires and during our site visit included that senior leaders from the provider organisation had rarely if ever visited the practice.

There was a policy in place with a named person for staff to contact however there was no evidence at the time of the assessment that staff were aware of who this was as there was no visible information displayed within the staff areas at the practice and the policy had been modified on 21 March 2025. There was no meeting structures in place that allowed for all staff at the practice to share, communicate, feedback and learn together.

Practice leaders did not always listen to and act on staff feedback and did not create a culture where staff felt empowered and valued.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Records provided for the assessment were incomplete and poorly organised. This included patient group directives, training records, health and safety risk assessments and staff files. Records had not been maintained of equipment calibration, emergency lighting and fire safety checks.

The governance process was not sufficiently developed and effective to ensure risks to people was minimised. The provider did not have oversight of monitoring systems to ensure action had been taken so that people received appropriate care and treatment when on high risk medicines. The training processes for staff had not been fully monitored to ensure staff received appropriate training to carry out their duties and had sufficient time to complete this training. Other areas which required improvement included handling of complaints and significant events to ensure trends and themes were identified, learning was shared appropriately; and actions taken were monitored.

The health and safety policy stated that a Health and Safety Executive poster needed to be displayed in the practice. This was not seen at the time of the site visit. This meant people did not have the information on who was responsible for health and safety within the practice. The policy also stated that there needed to be a nominated person responsible for maintaining health and safety within the practice and ensure appropriate risk assessments were carried out and action take, The practice did not have a nominated person and there was no clear overarching governance of health and safety within the practice for example emergency lighting was required to be checked daily, a monthly all system check was to be carried out and an annual service. We requested this information but were not provided with any evidence to demonstrate checks and maintenance had taken place.

Calibration of equipment had not been carried out annually as required in the practice policy, this meant the provider could not be assured that equipment was operating appropriately. There were no calibration records since 2023.

We requested evidence of up to date public liability insurance; as documentation viewed on the date of our site visit showed that it had lapsed on 29 June 2024. Following the site visit we were provided with information which showed that the public liability insurance had been renewed on 18 March 2025. This meant that there was a gap of almost 9 months when appropriate public liability insurance was not in place. We found that this situation was the same for employers’ liability insurance., which had lapsed on 22 November 2024 and was not renewed until 18 March 2025.

There was a lack of risk management to include the building, staff members and specific working practices. There was no risk register to detail the actions to manage and reduce any known risk. For example, there was a lack of oversight of maintenance and updating of the premises to ensure they were safe for people who used the service and staff.

The practice provided limited evidence on how it worked with other service providers and the wider community. We were told that the practice was part of a primary care network (PCN), but there were no structures in place to indicate how often the practice met with the PCN to discuss service provision in the local area.

The practice did not have a structured process in place to promote learning, improvement and innovation. We requested information on how learning was shared and what quality improvement and clinical audits were carried out Information was either not provided or lacked detail on how the service would be monitored and developed.