The Armada Family 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 has changed from good to requires improvement
The service was in breach of legal regulation in relation to good governance. There was a lack of effective oversight to ensure systems and processes operated consistently, including learning from incidents, medicines management, recruitment, infection prevention and control, and complaints handling.
 

This service scored 61 (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 vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, some staff told us they were not aware of the service’s vision and longer-term plans. Strategy and business planning meetings were being held by leaders of the service, but the outcomes of the meetings had not been effectively communicated to all staff.

Staff told us they had the opportunity to attend meetings including practice, clinical and safeguarding. Clinical meetings took place twice a month on different days of the week to accommodate different work patterns. However, some staff told us it was not always easy to attend these meetings as they either had appointments booked in or had non-clinical tasks that needed to be carried out. Leaders told us they were aware not all staff could attend these meetings, however, a representative from each team was able to attend and feedback to staff.
 

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Staff reported leaders were visible, approachable, and genuinely cared about them. However, some staff reported they did not feel confident action was taken by leaders when concerns were raised.
Leaders recognised the importance of staff wellbeing and helped to coordinate flexible working so people could achieve a good work/life balance.
 

The service had Freedom to Speak Up Guardian (FTSUG) arrangements, but not all staff were aware of them.
The service had a policy for FTSU embedded within its whistleblowing policy. The policy was updated in 2025 to reflect changes made to the FTSU service.Staff told us they felt they could raise concerns in relation to safe patient care.

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.
We saw examples of workplace adjustments to support different needs. Staff gave examples of reasonable adjustments the service had made to support them both at work and in personal circumstances.
Staff had access to an equality, diversity, and inclusion policy. Training on equality, diversity and inclusion was also available to support staff in understanding protected characteristics, bullying, and harassment. However, not all staff had up to date training in this area at the time of our onsite visit.
 

The service did not have clear systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The provider had not established governance processes that were appropriate for the service, nor ensured effective oversight of all processes were operated as required.
For example, the service’s system and process to ensure learning from incidents was shared with staff was not effective. From our review, some incidents had not had any learning identified and, for others, the service was unable to demonstrate how and when learning was shared with staff. Staff confirmed they were not always made aware of learning from incidents.
The service’s systems and processes to manage medicines to ensure medicines were prescribed and administered safely, and relevant monitoring tests or reviews were carried out were not effective. In addition, information was not consistently provided to people on potential interactions of medicines they were prescribed.
The service’s recruitment processes were also not in line with national legislation. The service’s own recruitment policy did not include all relevant details to make sure it complied with Schedule 3 of the Health and Social Care Act. Subsequently, the service’s staff files did not contain all information to evidence safe recruitment was undertaken in line with it. The service was also unable to demonstrate staff were competent to carry out their roles, as staff had not consistently completed the training required by the service’s own expectations, nor had they received ongoing clinical supervision, and not all staff had received an annual appraisal in line with the service’s policy.
Although the service’s infection prevention and control policy stipulated audits should take place 6 monthly, evidence of these audits having taken place was not available at the time of our assessment.
Leaders had failed to identify the process for managing complaints was not effective. For example, complaints were not being consistently managed in line with their own policy, nor had they ensured people were signposted to other agencies if they were not satisfied with the outcome of the service’s investigation.
The service took action in response to feedback on our onsite visit, such as immediately scheduling appraisals for staff and reviewing processes related to medicine management.
However, all staff we spoke with were clear on their individual roles and responsibilities within the service.
 

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.
The service had an active patient participation group (PPG) and worked in partnership with members to seek feedback and support service improvement. For example, PPG members told the service that some people found it difficult to understand how to access appointments. In response, the service reviewed the information available to people and improved communication through the service website and patient information materials to make access routes clearer.
Partners told us the service ensured appropriate actions were taken to support vulnerable people and to manage concerns when they were raised. They explained that staff were aware of people who may require additional support and took steps to ensure their needs were considered when delivering care and responding to issues.
The service demonstrated an understanding of its population and had adapted services to meet identified needs. For example, there were effective working links with the social prescribing team.
 

The service contributed to safe, effective practice, working within a multi-disciplinary team to provide the right support for everyone.
The service was open to trying new ways of working and had put themselves forward for projects such as group sessions for people prescribed hormone replacement therapy (HRT) or menopause; and projects with the aim of increasing the uptake of cervical screening.The service had also trialled new ways of working such as the use of artificial intelligence and automation and programmes to improve how people register with the service.
The service had a quality improvement plan in place to help drive improvements in services and had undertaken a project aimed at improving the management of suspected urinary tract infections in children.
The service recognised that people had experienced difficulties contacting the service using the previous telephone system. In response, the service had implemented a new telephone system designed to improve accessibility.