Sheepcot 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 key question has been rated as Inadequate. The service was in breach of legal Regulation 17(1) and 17(2), Good Governance, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 50 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The staff we spoke with were not able to describe the practice vision and strategy and told us they had not been involved in design or implementation. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges, such cervical screening.

The service did not have 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 did not have the skills, knowledge, experience, and credibility to lead effectively. This was reflected by the lack of governance oversight at the practice. Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff told us they felt they could raise concerns and gain support from the leadership team. The provider encouraged staff feedback in meetings and staff told us they felt supported. Staff surveys were not completed regularly, nor were staff appraisals, therefore staff feedback was limited. Managers and leaders could account for the actions and behaviours of the staff. Leaders had implemented quality improvement frameworks to address the health inequalities known to the practice, such as obesity.

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 staff did speak positively about the leadership team and of each other and described a “family workforce”.

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. We saw senior leaders had addressed concerns related to discrimination, such as the provider being aware of the Equality Act. 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 have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The GP Partners and manager had an overall responsibility for performance monitoring. There was a lead GP partner for each clinical area. Any concerns regarding performance concern would be raised in a meeting with the other partners and management team. Our remote clinical searches identified some gaps within the safe prescribing of medicines, the management of MHRA alerts, long-term condition management, and access. Although the practice was making changes, these had not been reflected or fully embedded and would be assessed at the next inspection. The practice was making some improvements, however, there were still areas for development required; for example, the implementation of audits and staff appraisals, and increased infection, prevention, and control governance. There were improvements to patient referrals that could be implemented to allow clearer oversight. The concerns we found regarding emergency medicines had been reviewed following our assessment and the practice wanted to work towards addressing these barriers. We asked the provider to address all areas of concern we identified in their governance processes. We were provided evidence of these improvements to be made following our assessment.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement, for example, with external bodies such as the integrated care board and local primary care network. The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve the 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 did not always focus on continuous learning, innovation, and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not always actively contribute to safe, effective practice and research. The practice did not have a quality improvement plan in place to help drive improvements in services and lacked a formal process for making changes within the practice. We were told of changes that had been made such as, telephone access and changes following the significant event example shared, however, there was a lack of documentation of these changes or review processes. This meant the provider was unable to monitor and track progress effectively.