The Glebe Family Practice

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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 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 good. At this assessment, the rating remains the same.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The practice had responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. The provider had established governance processes that were appropriate for their service.

The practice now had established and effective governance systems to monitor vaccine supplies, including processes for checking expiry dates. Monthly audits were carried out, supported by a spreadsheet tracking system that highlighted items approaching expiry so that timely action could be taken. For example, reordering or removing items.

Practice nurses also carried out informal checks of vaccine expiry dates in each treatment room. These ad‑hoc checks were completed opportunistically during routine duties.

Oversight was maintained by the practice manager, who completed regular spot checks to ensure the process was being followed. During the inspection, we reviewed a random sample of vaccines and found all were in date. We also noted that items nearing expiry, such as those due to expire in the next month, were clearly highlighted on their packaging to ensure clinicians were aware.

The practice now had effective oversight of its task‑management system. Unactioned tasks had reduced and were monitored daily by senior staff. Weekly and monthly audits were conducted to ensure workloads remained manageable and that any urgent tasks were not overlooked. Clear policies were in place to guide staff on how tasks should be managed, and these had been shared and discussed with the team. Task management was also a standing agenda item at meetings, where leaders reviewed outstanding tasks, checked for any urgent items requiring action, and considered opportunities to further strengthen processes.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.