During an assessment under our new approach
Date of Assessment: 23 February 2026 to 04 March 2026. The Armada Family Practice is a GP practice and delivers service to approximately 16,300 people under a contract held with NHS England. The National General Practice Profiles states that the ethnic makeup of the practice is 93% White, 3% Asian, 2% Mixed and 2% Black and other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had an open learning culture where people felt comfortable to raise concerns. Incidents were reported and investigated. However, record keeping did not always clearly document incidents or evidence learning, when needed, had been identified and action taken.
People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained, and any risks were mitigated. However, leaders could not be assured that staff completed required training and received regular clinical supervision sessions and appraisals. Recruitment checks, including appropriate references, were not always in place.
Staff managed medicines and involved people in planning any changes. However, people who were prescribed certain medicines did not always receive the required monitoring; and people were not always made aware of the risks associated with combinations of some medicines.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to make decisions in people’s best interests where they did not have capacity.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. There was a complaints procedure. However, complaints were not always managed in line with this.
The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff had a shared vision and strategy. Leaders were visible and knowledgeable. There were systems and processes for staff to provide feedback. Staff felt supported to give feedback and were treated equally, free from bullying or harassment.
Staff understood their roles and responsibilities, and leaders helped staff develop in their roles. However, there was a lack of oversight to ensure tasks, that had been delegated, had been completed. For example, we found gaps in recruitment files to evidence staff had been safely recruited, which the service was not aware of prior to our assessment. There were governance systems, however these were not always effective. This included oversight of staff training completion, infection control audits, learning from complaints, significant events recording and ongoing clinical supervision.
We found breaches of the regulations in relation to good governance and staffing. We have asked the provider for an action plan in response to the concerns found at this assessment.