The Limes 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.

We saw that some staff had contributed to the development of the practice vision and strategy and they had inclusive leaders at all levels. The service fostered a positive culture where people felt they could speak up and their voice would be heard. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The service clearly understood and carried out their duty to collaborate and work in partnership, so services worked seamlessly for people.

Issues identified included concerns around inadequate management of significant events and notifying CQC of notifiable incidents and as a result, there were missed opportunities to identify and report safety incidents and share learning. The staff list did not accurately reflect the current staff working at the practice. The systems and processes in place to ensure learning and improvement was not robust and monitoring was required to ensure consistency in all these areas of learning but there was a strong focus on continuous innovation across the organisation

However, we found significant issues and gaps around clinical governance, learning and improvement.

The provider was in breach of legal regulation in relation to good governance and the provider has been rated requires improvement for providing a well-led service.

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.

We saw that some staff had contributed to the development of the practice vision and strategy, which was kept under review through annual strategic planning meetings, where leads discussed and set out goals and objectives for their individual teams and those of the practice. The practice Statement of Purpose did not provide much information in relation to their aims and objectives and what they wished to achieve by providing regulated activities, except to provide general medical services to the population. However, we saw their business development plan with a mission statement which was also displayed in the practice and aimed to deliver a high standard of care to patients, as well as a Practice Development plan for 2024-2027 created after consultation with the leadership team, and this highlighted their strategic aims and objectives, including their digital strategy.

The practice supported and encouraged new learning opportunities and took part in the locality’s dedicated Time to Learn sessions. They were part of the Epping North Primary Care Network (PCN) group of 6 practices and understood the challenges and the needs of people and their communities. The practice had demonstrated their shared vision of equality and human rights through providing support for their vulnerable population and were accredited as a boat friendly practice and veteran accredited practice in recognition for their support for the boating community and the veterans. They worked with partner agencies to address and meet the challenges of a growing population which outstripped supply and recognised the challenges their patients faced such as long waiting times for blood test in the hospitals, and they recognised that aggression towards their staff that was on the rise and measures were put in place to ensure staff safety. The practice had decided not to implement total triage, in favour of continuing contact with their patients.

All staff we spoke to had a clear shared vision and understood what the practice mission was. The culture was based on transparency, equity, diversity, inclusion and engagement and this was consistent with staff feedback where they described the culture of the practice as very supportive and welcoming. They had an equality and diversity lead. They also described a good working environment where there was a genuine sense of collaboration and staff at all levels were approachable and open to feedback. We saw happy and contented staff happy to come to work and an inclusive environment where staff felt valued and part of the team, professionally and at social events. The practice had a large proportion of staff who had worked there for many years and we did not receive any concerns regarding the culture of the practice during our inspection. We saw management working closely with staff on the front line and all leaders operated an open-door policy.

The service had 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. There were many different teams covering all 4 sites and the care homes and they were managed by designated leads and managers; for example, facilities lead, as well as front of house managers and supervisors. Staff told us leaders in the practice were visible, approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. The Primary Care Network’s (PCN) staff wellbeing survey carried out in February 2024 showed that 40 out of 43 respondents would recommend their organisation as a place to work and 3 neither agreed nor disagreed.

Leaders stayed alert to any examples of poor culture when appropriate. The practice had been recipients of awards in the past; for example, they won the ‘Practice of the year, management in practice’ award in 2008 and the ‘Transformation East of England Award’ in 2016.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Prior to the inspection, CQC sent all staff working at the practice individual staff feedback forms. The practice had a diverse workforce, so these feedback forms were confidential and voluntary, whilst offering the practice staff an opportunity to feedback their experiences of working at the practice, as well as to hear their individual voices in a way we would not normally have previously done on inspection due to time constraints. Of the 71 forms sent, we received 21 responses where staff gave us greater insight into their individual roles, including their understanding of the policies and procedures at the practice.

We also carried out staff interviews as part of the remote and onsite inspections on 24 and 26 June, as well as 1 July 2025. We spoke to a wide range of staff from front line reception staff, admin and clinical staff and staff were very complimentary and positive about working for the provider. All staff we spoke to and received feedback from were aware of how to raise concerns and felt confident in doing so and we saw examples where staff had used the arrangements in place to positive effect.

There was a whistleblowing policy, Freedom to Speak up policy as well as a bullying and harassment policy in place. The practice had an internal Freedom to Speak Up guardian which was not always appropriate for staff concerns. However, we saw they had also established Freedom to Speak up arrangements with another practice in the primary care network (PCN). We were not assured that all staff knew who their designated Freedom to Speak up guardian was.

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, inclusion and equality were in place; however, we found gaps in their processes. For example, there was a designated equality and diversity lead but the policy in place did not document the lead and what their role entailed.

The Primary Care Network (PCN) staff wellbeing survey carried out in February 2024 showed that 36 out of 44 respondents agreed that there was equality, diversity and inclusion in the practice, whilst 8 respondents said they did not know.

Staff had access to HR information, as well as the Employee Assistance Programme (EAP) and to a private healthcare provider. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support new parents working in the practice and staff were supported when coming from sickness absence. We saw that staff were treated fairly and celebrated in their staff newsletter, including during their birthdays and also during their ’60 seconds with’ interviews they had with different staff members that were published in their newsletter.

Staff reported no negative sense of hierarchy and they were comfortable to raise issues. Staff did not feel anything needed to be changed within the practice as the leaders listened to their suggestions on a regular basis through the use of the staff suggestion box and their meetings, so change was regularly considered and implemented. Other staff who suggested change felt the provider could look at ways to reduce duplication of work and they could work smarter as a team and make every contact count.

The practice manager provided Maths and English training following requests from their staff.

Staff had access to a suggestion box that was reviewed every month and staff feedback included a ‘you said, we did’ response from the leaders. We saw evidence where leaders acted on staff feedback and provided them with outcomes; for example, they agreed to 1:1 sessions with admin and secretarial staff for those who had just completed their probation in order to understand their processes better and leaders also agreed that staff could have a radio in the common room at their request. The PCN’s staff wellbeing survey carried out in February 2024 showed that 42 out of 44 respondents agreed that action was taken when concerns were reported, which was most of the staff who responded to the survey whilst 2 neither agreed nor disagreed.

The service had responsibilities, roles, systems of accountability; however, we found significant gaps in governance systems such as sharing and learning culture and they did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. This was in relation to their significant events and complaints where we were not assured that they were always captured, or that learning was shared with all staff, including those not present at any meetings.

We identified gaps in governance systems for monitoring mandatory training compliance, including equality and diversity training. Although the policy states this training should be completed annually, records showed five clinical and non-clinical staff were overdue and no evidence was available for five salaried and sessional GPs. Additionally, the equality and diversity policy focused primarily on employees and did not address patient-related considerations. Oversight was further limited as the training was not consistently recorded as mandatory for sessional GPs.

Most of the staff could access all required policies and procedures; however, monitoring was required to ensure newer staff could confidently access this information. There was a business continuity plan in place for all the 4 sites which was monitored and reviewed; however, not all staff were aware of this plan. Not all new staff were aware of policies in place.

Staff told us they took patient confidentiality and information security seriously; however, the governance systems were not effective enough to prevent the repeated data breach related incidents in the practice. On inspection we found 8 communication related significant events over a 6-month period and we were also not assured that effective improvements were made due to repeated data protection incidents. We identified instances of data breaches where confidential patient information was inappropriately disclosed in responses to NHS reviews. Examples included details of clinical procedures, such as steroid injections and information about patients’ positions on waiting lists. These disclosures breached confidentiality standards.

We also found some data breach examples where personal information was given to patients in response to their NHS reviews; for example, relating to the type of steroid injections they had received and their location on a waiting list.

We identified significant gaps in the provider’s compliance with CQC notification requirements under their registration conditions. The incident policy did not clearly outline which events must be reported to CQC, including serious incidents such as those investigated by the police or deaths occurring during the provision of regulated activities. This lack of clarity poses a risk to patient safety and legal compliance.

Gaps were also found in governance systems such as staff training, sharing of meeting minutes such as admin and nurse meeting minutes, medicines management including emergency medicines and equipment, infection control, health and fire safety.

Oversight of the three branch locations was limited, with expired consumables remaining in use and no policy governing wound photography.

The staff list was outdated and excluded some current employees, preventing accurate verification of staffing levels.

The systems and processes in place to ensure learning and improvement was not robust and monitoring was required to ensure consistency in all these areas of learning. This was due to gaps and weaknesses in processes and arrangements intended to identify and deliver learning and continuous improvement in areas such as significant events, duty of candour, patient care, complaints and overall governance of the practice.

The service clearly understood and carried out their duty to collaborate and work in partnership, so services worked seamlessly for people; for example, with their Epping Forest North Primary Care Network (PCN) and Hertfordshire and West Essex Integrated Care Board (HWEICB) colleagues. Both partners provided testimonials as part of the inspection and the PCN praised the key role the practice played in shaping strategic decisions and advocating for improvements that benefited their patients and wider network.

The provider collaborated with other practices within their primary care network (PCN) to offer extended access and vaccination programmes. Staff had made adjustments to improve 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 practice nurses collaborated with the PCN nurses and supported each other through their group instant messaging and PCN shutdown events. They had a large virtual Patient Population Group (PPG) of 600 patients (3% of the practice population) and we saw 2 meeting minutes where they met with the managing team during a face-to-face session with 20 PPG attendees. They arranged a host of PPG engagement events and were looking to launch PPG video sessions.

The practice told us their Patient Participation Group (PPG) was reflective of their practice population.

We also viewed complimentary feedback from several of their external partners praising the practice and their collaborative approach to patient care.

The Limes Medical Centre is a training/teaching practice, with a long-established record of both undergraduate and post graduate teaching, having been involved in the undergraduate teaching process for over 12 years and post graduate teaching for far longer. The practice is currently involved in the undergraduate teaching of nursing students from Anglia Ruskin University as well as paramedic students from the University of Hertfordshire.

The learning and development needs of staff were managed appropriately and staff felt there was a real focus on professional development and we saw evidence of this. For example, the provider supported staff to become accredited in undertaking spirometry testing and one of the GPs was supported to complete their educational supervisor training for GP registrars. We also saw their advanced nursing staff receive dermoscopy training to look at moles under microscope to recognise signs of benign or cancerous moles. There was a wide range of clinical and non-clinical roles within the practice, ranging from extended care practitioners (ECP’s) who had successfully completed the International Certificate of Palliative Care with 2 other staff. The practice led in the innovation of the Ctyosponge project by ensuring its successful implementation and improved patient care through early detection and intervention and took part in various projects including the East of England Health Inequalities project.

The practice was a training practice for over 40 years and recruited over at least 70 staff members who worked across all the 4 locations. There was a wide range of clinical and non-clinical roles within the practice, ranging from extended care practitioners (ECP’s) who had successfully completed the International Certificate of Palliative Care with 2 other staff. The practice also recruited clinical pharmacists to personal assistants and social prescribers.

We were told there were regular meetings including monthly nurse meetings but we did not see any meeting minutes. The practice also told us other meetings took place such as, whole practice meetings, staff meetings or administration staff meeting minutes provided. We were also not provided with the operations manager meeting minutes. Staff also told us they had evening practice meetings to discuss wider issues and they also attended Time to Learn sessions but no evidence was provided of minutes to show learning and cascading was taking place.

The practice had a quality improvement plan in place to help drive improvements in services that focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working, and we saw examples from the nursing staff.

The service had a focus on continuous innovation across the organisation and local systems. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They were exploring the use of AI in order to improve the time spent on minute taking. The practice had access to an NHS-compliant AI tool to improve documentation efficiency and quality and we saw examples of where this was used during various team meetings. We also saw that 2 GPs were piloting it in October 2024 to document consultations and if successful, would be rolled out to the rest of the team. Patient permission was required to use this system. Features included transcription, customisation, and multilingual options.