LADMS GP Enhanced Access Service - Alford Memorial Hall

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 had not inspected this service before. At this assessment we rated this key question as Requires Improvement. This meant the service was not well-led.

We looked for evidence that service leadership, and governance assured high-quality, person-centred care, promoting an open fair culture and supported learning and innovation. However, we found evidence that governance was not well-led .

Leaders were very compassionate and inclusive, and staff felt supported and valued. The culture they created promoted high-quality, person-centred 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. This was based on transparency, equity, equality, human rights, diversity and inclusion, and understanding the needs of people and their communities.

The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had a clear mission statement, which showed aspirations to provide the highest possible standard of professional interaction with people, staff and the wider health and well-being community. The service committed to provide high quality and accessible healthcare and to treat people with courtesy and respect.

Staff told us there had been a recent change of leaders and they were positive about the changes and culture within the service and described it as open, transparent and supportive.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

There had been significant changes in the leadership team in recent months due to staff turnover. New leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty. This was echoed by staff who spoke positively about the leadership, who stated that the managers were approachable and responded to any concerns raised.

The service had an equality and diversity policy and promoted equity to all people, including staff, with diverse needs and protected characteristics, such as sexuality (LGBTQIA+) age, religions, disability, race. Staff told us that leaders cared about their wellbeing and they felt supported.

Managers did not foster a positive culture where people felt they could speak up and their voice would be heard.

However, clinical and not clinical staff we spoke with were not aware of the arrangements and did not know who the freedom to speak up guardian was or if there was a Freedom to Speak up Guardian. Clinical staff we spoke with felt confident to speak with the director of nursing if they had concerns.

There were policies in place to support staff to whistle blow or to speak with a Freedom to Speak Up Guardian if they had any concerns. The practice had established Freedom to Speak up arrangements with the Integrated Care Board.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had a significant focus on staff wellbeing and had an enhanced induction and probation system to ensure new starters were well supported.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to work flexibly.

Leaders told us that they had have challenges with long term sickness of key members of staff and several changes within the staffing structure. There had been an unexpected turnover of key staff to include the general manager and director of nursing and chief nursing officer roles. These roles had since been recruited.

Managers failed to ensure the team had 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.

Leaders did not have safe processes and oversight of clinical staff files. The service’s electric dashboard recording compliance of staff files indicated that medical indemnity insurance, registration with the General Medical Council (GMC) or nursing and Midwifery Council registration (NMC) had not been recorded or had not been updated by the organisation. The service was unable to assure us that 2 GPs had valid medical indemnity insurance, nor that 4 GPs had valid and in-date registration with the GMC which was noted as expired or overdue. Clinical appraisals were not recorded for all staff members. We looked at 5 staff files; we found references were absent in 2 files. We also found that 2 GPs did not have a curriculum vitae (CV) on file.

Managers did not have established governance processes, they failed to ensure regular quality, risk and governance meetings were held. We were told that meetings should be held every 2 weeks. Whilst we saw diary invites for governance meetings during February and June 2025 there was no evidence that these had taken place. Managers told us they had recently reviewed governance arrangements and had implemented robust systems.

Leaders had identified that systems for the safe storage of key documentation and information to aid information sharing, learning and governance had been held in personal electronic files of staff leavers and they were now unable to access these files.

We were provided with “LADMS Operational Catch-up” meeting minutes. Action from these minutes indicated that several systems and processes had not been embedded and significant work was identified following the announcement of CQC’s onsite assessment. For example, communications pertaining to the emergency medical equipment and ensuring compliancy with the Health and Social Care regulations. During our assessment we found that managers did not ensure emergency equipment was consistent across localities. There were significant variances in the emergency equipment and leaders were unable to evidence to us that equipment was regularly checked and monitored.

Leaders did not have oversight of cleaning contracts within some of the premises’ used, and therefore, were unable to assure us that premises were clean and safe.

We were told that a restructure of administration support had recently taken place which aimed to standardise training, policies and procedures and checklists, to ensure continuity and consistency across the service.

Leaders had tools to monitor training. For example, diary dates were in place for monitoring staff training with reminders sent before training became overdue. However, mandatory information governance training compliance was 71% and mental capacity training compliance was 59%.

The service 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.

There were processes in place to work in partnership with key organisations and agencies to support the provision of care and joined up working. Staff told us they regularly went over and above for people by referring them to services within the community such as a health and wellbeing coach to support them to live healthier lives.

The service focused on continuous learning, innovation and improvement across the organisation and local system.

We were told that clinical leaders had oversight of the non-medical prescriber’s activity and completed regular audits to assess the appropriateness of medications prescribed and record keeping and ensure that people were safe.

We saw evidence that monthly audits were being completed. However, due to staff turnover and staff sickness the audits had not been completed since October 2025. Failure to complete regular clinical oversight was acknowledged within meeting minutes dated 7 April 2026, where leaders commented that they needed to undertake peer reviews and complete medication audits to provide quality improvement evidence in readiness for the announced CQC assessment.

Leaders told us that they used learning from people’s feedback, significant events and complaints to continually improve the service they provided, and changes were made within the practice if needed. However, staff members informed us that they had not been involved in any meetings to learn from significant events or complaints. We saw meeting minutes dated 20 January 2026 were leaders raised concerns that they needed to be more inclusive in the reviews of significant events and complaints, however we did not find evidence that this had been actioned or implemented.

We were told that significant event had occurred where a person who had attended the enhanced hours clinic became acutely unwell and required an emergency hospital admission. Whilst waiting for the ambulance service to attend on site the nurse in charge continued to provide care to the person. This resulted in people who were waiting to be seen being asked to return on another occasion. Leaders at the time reviewed the significant event and reprimanded the nurse for not continuing with planned appointments. The nurse involved told us they felt aggrieved that they had been chastised for prioritising the rapidly deteriorating person and rearranging appointments. The new leadership team reviewed the significant event and agreed that the nurse involved had taken the correct action, and they apologised to the nurse.