St Georges 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 Requires Improvement.

The service was in breach of legal regulation in relation to Good
Governance.

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 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 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 told us leaders in the practice were 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 service fostered a positive culture where people felt they could speak up and their voice would be heard.

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 we saw examples where staff had used the arrangements in place to positive effect.

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. Adjustments had been made to ensure all staff were valued; for example, we saw adjustments to support disabled staff were in place.

The service 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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers did not meet with staff regularly to complete appraisals and performance reviews.

The provider had governance processes in place; however, these were not robust in all areas, and they did not have an effective system in place to monitor and mitigate risks. The provider had failed to identify several issues we identified during inspection, for example, management of prescriptions, safe environment and infection prevention and control. The provider responded to some of the concerns raised immediately following inspection; however, this action was only taken after our intervention, and not as a result of their governance and management oversight.

Staff could access all required policies and procedures.

Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks.The provider told us they shared the minutes of the meetings with all staff, however on the day of the inspection, some staff advised us that they did not receive minutes from the meetings.

Staff took patient confidentiality and information security seriously. All mandatory training required by staff was completed and up to date.

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.

Service users of the practice were able to access extended hours appointments through the primary care network (PCN). The practice worked with community and secondary care colleagues to provide joined-up care. The provider did not always work closely with the PCN on other initiatives in the local area and due to the limited size of the practice the provider was limited on what they could offer the community in terms of holding community support events at the practice.

The service focused on continuous learning and improvement across the organisation. 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.