Abbey 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 Good. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff feedback showed they understood their roles and responsibilities.

Managers worked with the local community and the primary care network (PCN) to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement, with staff given resources to suggest new ideas and areas of improvement. The majority of staff feedback we received was positive around the culture of the practice.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good

This service scored 75 (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 practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Being a small practice, it enabled the providers to have better oversight, allowing better staff engagement and more tailored patient outreach.

Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to deliver high-quality, patient-centred care. Staff feedback suggested effective communication, however some team members stated they did not feel included in decision making processes relating to the service.

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. Staff feedback reported that the new management had the skills, knowledge, and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised.

Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns and did speak positively about the leadership team.

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.

A sample of staff records indicated that all staff had received and were up to date with equality and diversity training as part of the practice’s mandatory training requirements.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support.

Staff had access to all required policies and procedures. Practice meetings with staff were held regularly, during which they discussed clinical concerns and emerging risks.

We reviewed a sample of minutes from all the meetings for the previous months. We noted practice’s clinical meetings were held regularly and had clearly recorded actions that were shared with staff at the practice.

Staff took patient confidentiality and information security seriously.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people.

We saw that the practice worked with other practices within their PCN to provide extended access and treatment room services. The practice was 1 of 3 that formed the PCN, with the same group of partners overseeing all 3 practices. This enabled shared vision and cohesive implementation of initiative across the PCN.

The service had a strong focus 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 contribute to safe, effective practice and research.

Staff were particularly proud of their achievements in establishing the treatment room. Staff told us patients valued this, and it had contributed to improved patient satisfaction.

Our clinical searches showed robust systems were in place to assess the quality of the service and monitor patient outcomes. Where areas for improvement were identified, appropriate actions were taken to enhance service delivery and prevent recurrence. We noted that the provider monitored and tracked learnings to make improvements effectively.

The practice had a quality improvement plan in place to support service development, and completed audits evidenced positive outcomes. For example, the prescribing audit and the Short-acting beta-2 agonists inhaler (SABA) audit for review of asthmatic patients issued 6 more inhalers in the last 12 months. As the result there was a reduction in number of patients overordering SABA inhalers, and improvements were noted in inhaler technique through use of spacer use.