Bethnal Green Health 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. The service was in breach of legal regulations because they did not ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care. At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement. This meant leaders and managers did not always have effective oversight of systems and processes to promote safe service provision. For example, staff had not always followed practice policies on staff training and recruitment, infection control and prescribing, or followed national guidelines to ensure patients were kept safe. New systems had recently been implemented; however, further work was needed to embed some systems. The provider acknowledged these findings and stated that key processes have been reviewed and reinforced following our feedback.

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. All staff we spoke with shared the provider’s desire to deliver high quality patient-centred care and foster a strong partnership with patients to achieve the best possible health outcomes.

Leaders and practice staff understood their patient population, including cultural needs and wider challenges. Staff told us it was a positive workplace where they felt well supported by their leaders. However, improvements were needed to training provision to ensure that staff were well supported and received appropriate training and development. All staff had contributed to the development of the practice vision and strategy, which was kept under review. The service had developed values that would help them achieve this vision.

Leaders and managers did not always demonstrate they had the experience, capacity and capability to ensure that the organisational vision could be delivered, and risks were well managed. However, we observed leaders were visible and accessible, and staff told us they felt supported to deliver safe and effective care.

The leaders told us they operated a no-blame learning culture which provided all staff with an open and equal working relationship. Leaders we spoke with understood the importance of protecting individuals from discrimination and promoting equality in the workplace. The service had recently reviewed its complaints investigation process, to improve people’s experience of making a complaint to the service. However, leaders did not always demonstrate they understood all risks to delivering safe care. For example, we identified staff training compliance was not monitored effectively. The provider did however take appropriate action to monitor training completion when we raised concerns with them during the assessment.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had an independent Freedom to Speak Up Guardian for staff to speak with. Staff we spoke with said they would feel comfortable in making their views heard. However, 3 members of staff we spoke with did not know who the Freedom to Speak Up guardian was (FTSU). Information about the freedom guardian was available as a poster in staff areas but contact information was not included in the Staff Handbook. A member of the PCN acted as the independent freedom to speak up guardian for staff to speak to.

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 and equality were in place. The provider offered occupational health services for staff and leaders took steps to meet wellbeing needs by providing appropriate resources, regular breaks, and safe working environments. The leaders offered flexible working for staff with childcare, disability or cultural needs.

Leaders provided training to ensure staff were aware of their rights, including those related to equality, dignity, and respect in the workplace. Leaders told us they valued and supported all team members. In 2025, the practice had worked with the Vocational Training Scheme (VTS) group to support disabled member of staff who joined the practice. The staff member visited the practice a month before their start date, and the service discussed their reasonable adjustments and ensured that the lifts and access routes were all fully accessible.

Leaders held regular meetings where staff could raise concerns. We observed that the practice operated a clinical hub room that was open throughout working hours and served as a safe, supportive space for both experienced and more junior staff to seek advice or share concerns. Staff reported being supported if they were struggling at work. Staff members told us they felt encouraged to contribute their ideas.

We found the provider did not have clear and effective governance processes, which supported the safe delivery of care. The provider did not always have clear responsibilities, roles and systems of accountability.

Oversight of safety systems required strengthening to ensure staff consistently followed policies. Staff had not always followed practice policies in relation to infection control, recruitment checks and staff training. Managers had not met with all staff annually to complete appraisals and performance reviews. Systems for responding to medicines safety alerts and documenting DNACPR decisions required improvement.

Regular searches of the clinical record system were being run to identify patient needs and ensure these were being met. However, our review of clinical records showed that this was not always effective. Consistency in the monitoring of people’s medicines was needed to make sure blood tests were carried out prior to a review or prescription being issued.

Staff had opportunities to discuss incidents, complaints and safeguarding concerns as well as complex patients. Leaders had taken action to implement formal monitoring to ensure that learning following complaints and incidents was embedded and that actions had been successful.

Staff could access all required policies and procedures. At the time of our assessment, leaders explained that policies were being migrated to a new compliance software platform which they had recently purchased. Managers held regular practice meetings during which they discussed clinical concerns and emerging risks. Leaders held daily huddle meetings for any team member to attend where clinical and non-clinical staff could raise issues and contribute ideas. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

Staff we spoke with knew who the relevant lead person was for areas such as safeguarding, infection control and significant events monitoring. Staff took patient confidentiality and information security seriously.

The practice was part of the local primary care network, and the lead GP attended their meetings. Staff worked with other practices within their primary care network to offer extended access, referral to rapid response, domiciliary phlebotomy for housebound patients and flu, shingles and covid vaccination programmes. The practice was engaged in local community projects and PCN initiatives, to improve the practice and quality of care for the local population. The safeguarding lead told us they participated in multi-disciplinary safeguarding meetings and regularly attended meetings with external healthcare partners to discuss learning and improve outcomes for safeguarding.

There was a patient participation group (PPG) who represented the views of people using the service. We spoke with members of the group who stated staff were open and listened to their feedback.

Leaders focused on continuous learning and improvement across the organisation and local system. Staff told us they felt proud to be a training service affiliated with Queen Mary University of London and regularly hosted medical students and GP trainees. The service had 2 qualified GP trainers and 4 GP registrars. Although some staff had not received an annual appraisal, leaders told us they took staff development seriously. For example, leaders had supported a member of staff to train to become a GP Assistant at the practice. The practice had promoted three experienced reception staff to project lead roles to support them to take on further responsibility in their roles. Leaders told us they had worked with the council to help enable pupils in a local secondary school to get into health and social care. The practice approached the council to create a short-term placement linked to a council project to help people with mental health illnesses get work experience in healthcare services.

The practice introduced a GP-led total triage model using a centralised clinical hub. Multidisciplinary staff triaged and signposted all requests at first contact, supported by clear triage guidance and regular review. To manage a high volume of prescribing queries, leaders introduced a prescribing workflow and co‑located a clinical pharmacist within the hub to work alongside the GP hub supervisor and admin support. The service provided evidence of clinical and non-clinical audits which actively contributed to safe, effective practice and research. All staff were encouraged to put forward and test out new ways of working. Following our inspection, leaders sent us their response to our findings and told us they had reflected and would review ways to improve processes to ensure all staff and managers consistently followed practice policies.