Dr Gulzar Ahmed Also known as Crompton 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

At our last assessment, we rated this key question as requires improvement. The service was in breach of legal regulation in relation to regulation 17 Good governance because of shortfalls in governance systems.

At this assessment, the rating has changed to good as the provider demonstrated they had made the necessary improvements.

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. The practice’s mission statement and vision were displayed throughout the practice to remind staff of the shared goals and staff we spoke to understood these.

Since our last inspection the provider had made changes to the leadership of the practice. A new GP clinical lead had been recently recruited to work alongside the principal GP to strengthen clinical oversight. They demonstrated through our assessment process that they had the skills, knowledge and experience to lead effectively. In addition, a new practice manager had been recently recruited who demonstrated through our assessment process effective managerial oversight.

Staff told us leaders in the practice was 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.

The service fostered a positive culture where people felt they could speak up, and their voice would be heard. The provider had a Freedom to Speak Up policy which was available to staff. Staff we spoke to said they would access the policy if they needed to. We reviewed the policy and found it detailed both internal and external speaking up arrangements.

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 service had clear responsibilities, roles, systems of accountability and good governance. These were displayed throughout the practice. The provider 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 shared 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 worked in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. The provider worked with other practices within their primary care network to offer extended access. The provider coordinated with community healthcare services where necessary.

The service showed evidence of learning and improvement. The provider had an improvement plan which focused on patient experience. The objectives of the plan were to improve performance, access, communication with patients, strengthening of leadership and governance and delivering high quality care. The plan detailed key targets and timelines for completion.