Clement Road Medical Practice

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 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.

The service had a shared vision, strategy and culture. Its vision and aims were based on providing safety, excellence, learning together and compassion. Its vision was to be a practice built on trust and by delivering outstanding, equitable care to every patient registered.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Staff told us they felt included in decision making processes relating to the service and that leaders were visible.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning.

There was an open culture and clear learning within the practice. Regular meetings were held with staff, and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us that their wellbeing was considered, and their views respected, and concerns acted upon. Staff consistently described leaders as approachable, visible, and responsive. They reported feeling listened to and supported, with concerns addressed promptly and constructively. A GP Partner served as the Clinical Director within the Primary Care Network (PCN), and we saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

The practice had a positive culture where people knew they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with a clear and detailed policy staff could follow. Staff confirmed they were aware of how to raise concerns outside of the organisation. Staff had received training in whistleblowing.

The service valued diversity in their workforce and demonstrated an inclusive and fair culture by improving equality and equity for people who work for them.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles, and training opportunities were available.

The service had clear responsibilities, roles, systems of accountability and good governance. They 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.

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 practice carried out regular audits and quality improvement activities to monitor service provision and drive improvements. This included audits of prescribing and medicines management, as well as annual reviews of complaints and significant events. Findings were used to identify themes, trends, and learning opportunities, helping to inform actions and improve the quality and safety of services provided.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They share information and learning with partners and collaborate for improvement.

A GP within the practice was the clinical director within the Primary Care Network (PCN) and leaders collaborated with practices to deliver extended access and other health promotion activities. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

At the time of our assessment, there was no active Patient Participation Group (PPG) due to limited engagement despite the practice's efforts to recruit members. The practice recognised the value of patient involvement and was taking steps to re-establish the group to help ensure the views and experiences of people using the service were represented.

The practice offered extended access, flu and covid vaccination programmes.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. For example, the practice regularly reviewed and adapted its access arrangements to better meet the needs of its population and continued to evaluate and refine these approaches to support ongoing improvement.

The practice had a quality improvement plan in place to drive service development, and audits were carried out regularly. Learning from events, incidents and complaints was used to inform improvements and strengthen the quality of care.

The clinical team continually reviewed clinical guidelines and carried out regular audits to ensure patients received high-quality sustainable care.

The practice operated as a training environment, with a designated GP responsible for overseeing the development of trainee GPs. Structured time was allocated for case discussions, observed consultations, and topic-based teaching sessions.