Sarephed 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

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 provider had a vision and strategy for how they wanted to improve the service people received and the environment in which services were being delivered. Since registering with the Care Quality Commission (CQC) the provider had appointed a business manager who was working towards achieving this. For example, the installation of a lift so people who currently could not access upstairs would be able to.

Governance processes were regularly reviewed. The vision and plans for the service were shared with staff on a regular basis. We found that the culture within the service was one of staff supporting each other and we saw when staff needed support managers would at times cover reception when needed.

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.

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.

Staff we spoke with told us leaders and managers were all approachable and they worked within an environment that was open, friendly and considerate.

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

The provider had developed a freedom to speak up environment within the workplace. Staff were also aware of the whistleblowing policy which allowed them to share concerns where needed.

The practice had established Freedom to Speak up arrangements with other practices in the (PCN). Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They worked 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. The provider had procedures in place to ensure all staff were valued, for example we saw that an Equality and Diversity policy was in place.

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

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

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.

The provider was part of the local (PCN) which provided consistency and continuity of service to people’s care and treatment.

The provider worked with other practices within the PCN to offer extended access, flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

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 contributed to safe, effective practice and research.

The provider had systems and processes in place to support staff learning and improve the service people received. Regular staff meetings took place as part of ensuring information was shared and staff were able to check information and ask questions where needed. The provider had a business plan in place to improve the environment in which care and treatment was delivered. For example, they wanted to put a lift into the building to support people with difficulties getting upstairs.

The provider reviewed data from surveys and used friends and family information to support the improvement of the service.

The practice had a quality improvement plan in place to help drive improvements in services. The plan focussed on improving several areas, which included the environment and access to services.