Worden 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.The service is in breach of legal regulations 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, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

Staff had contributed to the development of the service’s vision and strategy, and there was a practice business plan. Leaders monitored and reviewed the progress of the business plan. The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years, and they had plans in place to manage this. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

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 service did not have clear 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.

Governance systems were not effective. These included systems for managing staff recruitment, environmental safety and prescription security. Some policies did not contain enough information to guide staff or were not followed. The recruitment policy included what information the service should gather prior to employing staff, but this was not followed. The fire policy stated that the fire risk assessment would be carried out annually, and there would be an annual fire drill. This did not happen. In addition, the was no adequate record of the fire evacuation. The health and safety policy stated risk assessments would be carried out ‘when required’. This did not guide staff appropriately, and a risk assessment had not been carried out for over 6 years. There was no overarching infection prevention and control policy in place to guide staff.

The fire risk assessment carried out in July 2023 was annotated that it would be repeated in July 2024, but it had not been repeated. The health and safety risk assessment carried out in June 2020 was annotated that it would be repeated in June 2021, but it had not been repeated.

Leaders held regular meetings with staff, but the risks we found had not been identified or discussed.

Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations. Staff submitted data and notifications to external agencies as required.

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.