Abbey Meads Medical Group

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 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.

The service had a clear shared vision and culture, supported by a defined strategy and mission statement. The vision and strategy were communicated to staff and the wider community, including through the service website. Staff described the culture as friendly, compassionate, supportive and professional.

Staff were actively involved in developing the service vision and strategy, which was regularly reviewed and discussed at quarterly meetings. Leader promoted learning and development and supported staff to access leadership programmes and specialist training, including asthma management and non-medical prescribing.

Leaders understood the challenges and opportunities associated with expected growth in the local population and worked with partner agencies, including the primary care network and local GP federation, to plan for future demand and service sustainability.

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.

People using the service were central to its improvement activities. Leaders used feedback from people and staff, together with performance data and assessment findings, to monitor progress and identify opportunities for improvement. Actions introduced as a result included lunch-and-learn sessions and an outdoor seating area to support staff wellbeing and team connection.

The service completed an annual staff survey and shared the findings with staff. Results showed improvements in staff experience, including an increase in the proportion of staff who said it was easy to learn from others, from 56% in 2023 to 100% in 2024. Leaders responded by creating additional opportunities for staff to share knowledge, reflect on practice and learn from one another, with progress monitored through future staff surveys.

Leaders also worked collaboratively with primary care network partners to support local service development through shared planning, service improvement discussions and joint initiatives designed to improve access and outcomes for local people.

The service had a clear staffing structure, and staff understood their roles and responsibilities. Staff described leaders as approachable, responsive and available when advice or support was needed. They also described an open and supportive culture where they felt valued, listened to and able to raise concerns.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had Freedom to Speak Up arrangements in place through the primary care network and GP federation, including access to a Freedom to Speak Up Guardian. Staff told us they understood how to raise concerns and could do so through team meetings, directly with managers or through formal speaking-up routes.

Staff described an open and supportive culture where leaders were approachable, welcomed feedback and encouraged ideas for improvement. Staff said they felt able to raise concerns and were confident these would be listened to and acted upon.

The service had a zero-tolerance approach to abuse of staff and systems in place to protect staff from inappropriate behaviour and reduce the risk of recurrence.

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.

The service had policies and procedures to promote equality, diversity and inclusion for both staff and people using the service. Leaders said the workforce reflected the local community and supported the delivery of personalised care. No concerns relating to discrimination had been reported, and staff said diversity was welcomed and respected. Leaders maintained a zero-tolerance approach to discrimination and acted promptly on any concerns involving staff or people using the service.

Staff had completed equality, diversity and inclusion training and understood how to support people with protected characteristics, including age, gender, religion and disability. Leaders also demonstrated consideration for staff members’ individual needs and cultural beliefs. For example, working hours were adjusted during Ramadan to support religious observance. Staff told us this helped create a positive and inclusive culture where diversity was recognised and valued.

Leaders promoted equal access to development and career progression opportunities. Staff had progressed within the service, including a receptionist who was being supported to develop into an administrator role. Staff said they felt valued, respected and included, and that opportunities for development were available regardless of background.

Reasonable adjustments were made to support staff in their roles and promote inclusion. This included flexible working arrangements for staff with childcare or other caring responsibilities. Leaders also promoted wellbeing through social events, helping strengthen inclusion, team relationships and a supportive workplace culture.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders supported staff and ensured they were clear about their roles and responsibilities. Staff received regular appraisals and performance reviews. Regular staff meetings provided opportunities to discuss clinical concerns, operational issues and emerging risks. Actions were recorded, shared and monitored to support accountability and follow-up.

The service had governance processes appropriate to its size and activity. Staff could access relevant policies and procedures and understood their responsibilities relating to confidentiality and information security. A business continuity plan provided clear guidance for responding to system failures and emergencies, including power outages, environmental hazards, severe weather and staff sickness.

Governance arrangements were supported by regular oversight of quality, performance and risk. Leaders used audits, clinical searches, staff meetings and action tracking to monitor areas including prescribing safety, long-term condition management, document processing, cervical screening uptake, minor surgery and access. Where variation or risk was identified, leaders took action, monitored progress and shared learning with staff to support improvement.

The service completed a programme of audits to monitor the quality and safety of care and treatment. Audit findings were used to identify improvements and support safe, effective and high-quality care.

Leaders were aware of planned local housing development and population growth and considered these factors to support future service sustainability.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders used information about population growth, deprivation and local access needs to inform services delivery and future planning. This included developing services such as extended access, vaccination programmes and community-based support in collaboration with the primary care network and GP federation.

Staff worked proactively with healthcare partners, including district nursing teams and secondary care services, to support coordinated and joined-up care for people using the service. Leaders also contributed to wider learning and improvement across the primary care network. For example, findings from an internal audit of the Heidi AI Scribe tool, an NHS-approved transcription tool used in consultations, were shared with partner organisations to support learning, innovation and service improvement.

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 contribute to safe, effective practice and research.

The service had a business improvement plan to support service development. Priorities included reducing GP appointment waiting times, increasing digital bookings, improving people satisfaction and reducing staff absence. Staff were encouraged to suggest and test new approaches, and inspectors saw examples of this during the assessment. Leaders promoted a culture of learning and reflection, using research, collaboration, best practice and feedback from people and the community to drive measurable improvement.

The service worked with the local primary care network (PCN) to support health initiatives focused on learning disabilities, cancer and immunisations. For example, the provider hosted a PCN carer roadshow for people registered with its services. Feedback from the previous event was used to improve the experience, including arranging transport for people who may otherwise have been unable to attend. The event promoted awareness of available support and services, , With clinicians, charities and specialists providing advice, information and follow-up support where needed. Other PCNs attended to learn from the approach and consider adopting similar initiatives for their own populations.

The service used technology to improve quality and efficiency of care. With people’s consent, the service introduced Heidi AI Scribe, an NHS-approved consultation transcription tool. Following feedback that note-taking during mental health consultations could affect engagement, the service used the tool to support more effective interactions while maintaining accurate clinical records. This enabled clinicians to spend more time listening to and engaging with people during consultations and less time typing notes.

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