Glenroyd Medical

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• 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 the practice’s leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open, fair culture.

The practice did not have leaders at all levels who understood the context in which they delivered care, treatment and support. They did not show they had the skills, knowledge, or experience to lead effectively. The practice did not have clear responsibilities, roles, systems of accountability and good governance. Risks had not been identified, and risks that had been highlighted to the practice had not been acted on.

At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to inadequate.The service was in breach of a legal regulation in relation to good governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice did not have a clear shared vision, strategy and culture. The majority of staff told us they were not involved in the development of the practice, such as developing a mission statement, vision or values. We asked the practice for their business plan. They said the plan for the year had not yet been compiled as it was the beginning of the year, but they gave us informal ideas for the year.

The practice’s statement of purpose detailed their aims and objectives. These included maintaining high quality of care through continuous learning and training and ensuring that all staff had the right skills and competency to deliver the required standard of care. We saw that managers did not have an oversight of what training was required or had been completed. Some of the general information we requested during our assessment could not be provided because the only person who held it was not available.

Some staff reported that communication within the practice was poor, and that communication within the wider team needed to be improved.

The practice did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not show they had the skills, knowledge, or experience to lead effectively.

There were several managers within the practice, but teams worked in silos and there was no-one with overall oversight or a full understanding of the practice. The managers had not received any supervision or appraisals for several years. Although the majority of staff told us that leaders were visible and approachable, staff told us that communication within the practice needed to be improved.

Leaders were not knowledgeable about issues and priorities for the quality of services. They had not been aware of the issues that we found during the assessment.

In the latest independent staff survey 64% of staff said they sometimes had unrealistic time pressures and 14% said they always had unrealistic time pressures. 64% said they had felt unwell due to work-related stress in the past year and 86% said that in the last 3 months they had gone to work despite not feeling well enough to perform their duties. The business manager told us they were thinking of running their own survey as only 28% of staff had sent in a response. We spoke with staff in the clinical hub. They told us they felt supported by the partners and felt empowered to suggest and implement initiatives.

The practice provided us with their whistleblowing policy. This was undated. Although a Freedom to Speak Up Guardian was mentioned, the name of that individual had been left blank. Staff told us the Freedom to Speak Up Guardian was the registered Manager. We saw that this information was on notices dated April 2025 displayed in the practice. The business manager told us they had updated their noticeboards since we announced our assessment. The notices also provided information of people outside the practice staff could go to. However, staff only named the Registered Manager as the named contact.

The practice 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. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff.

The practice 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.

There had been a change in the partners of the practice in 2020, and there had been no application to add a new partner to the practice’s CQC registration. The Registered Manager was informed this must be completed as a matter of urgency.

Roles, responsibilities and accountability arrangements were not clear. We asked for the job description of 5 managers. We were told job descriptions were in place, but they could not be located. Staff were not given accurate and honest feedback about how they were performing, or where improvement was needed; there was no formal appraisal in place for staff other than the administrative team.

Managers and staff on different teams worked in silos, and communication between teams was poor.

Systems for identifying, capturing and managing risks and issues were ineffective. The system for managing complaints was not effective. The system for managing significant events was also not effective; not all incidents and complaints were being recorded and staff reported that they were not invited to meetings where the incidents and complaints were discussed.

There was no effective system for managing environmental risks. Required actions had not been completed following a fire risk assessment in 2021, and leaders were unaware that any action had been required. Risks relating to infection prevention and control and medicine management had also not been identified.

Although team meetings were held, these were often informal with actions that could be shared with staff not being clearly recorded. Policies were not well-managed, and we were provided with policies that needed to be updated, or did not contain enough detail to guide staff.

The practice had an active patient participation group (PPG). The practice told us there were 8 members, but they did not represent the demographics of their patient population. They said they needed to start talking to other patients to provide a more representative view and encourage change. Minutes were usually kept of PPG meetings, but these were not up to date. The PPG had carried out surveys in the past, but there was a very poor response rate so results could not be analysed. The business manager told us they were keen for the PPG to carry out another survey, but they could not agree on a format.

The practice was active in their Primary Care Network (PCN) and told us they gave presentations to other practices within the Integrated Care Board (ICB) area to share good practice.

The practice did not focus on continuous learning, innovation and improvement across the organisation. Processes to ensure that learning was shared when there were incidents were not effective. A lot of staff, including clinical staff, fed back that they were not invited to meetings where significant events were discussed, so this did not help with learning. In addition, we saw not all significant events were recorded or actioned appropriately as per the provider’s own policy.

We asked the practice to provide us with evidence that the quality of treatment and services had been monitored within the last 12 months, including 2 completed clinical audit cycles. The practice provided us with some clinical audits but none of these had been repeated to provide evidence of improvement.The nurse manager was line-managed and previously appraised by a non-clinical manager.

There were regular staff meetings, but these were rarely for the whole practice team and few minutes were kept. The business manager told us staff did not have time to read minutes, so they usually provided brief bullet points about meetings they held to inform staff who had not been present. They were behind with providing these updates. One team described poor communication within the practice and the need for improvement.

The practice was a training practice. They told us that formal supervision was provided for doctors training to be GPs, but there was no formal supervision or appraisal for other clinicians working at the practice. The practice was a training practice. They told us that formal supervision was provided for doctors training to be GPs, but there was no formal supervision or appraisal for other clinicians working at the practice. Following the assessment, they provided evidence that there was some assessment and supervision for clinical staff. Non-clinical staff had their first appraisal in 5 years earlier in 2025, and managers had not had an appraisal for several years.Non-clinical staff had their first appraisal in 5 years earlier in 2025, and managers had not had an appraisal for several years.