Belmont Health Centre Also known as Dr J Wijeratne & Parnters

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-centres care; supported learning and innovation and promoted an open, fair culture. At our last assessment in July 2018, 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 regulation 17, related to good governance.

This service scored 57 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff understood the direction and culture of the service to be patient-focussed and high-quality care.

Staff told us leaders were approachable and they could raise any concerns with them. There were various leads for specific roles to ensure service delivery for the patient population and the wellbeing of staff.

The service fostered a positive culture where people felt they could speak up and their voices would be heard. Staff were aware of how to raise concerns internally but not externally. The service had a whistleblowing policy with the information of how staff can speak up externally, but staff we spoke to could not demonstrate awareness of this during the site visit.

The service valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff had awareness and training on equality.

The service did not have clear responsibilities, roles, systems of accountability and good governance. This was related to administrative oversight, effectiveness of the processes or systems, as revealed by the evidence obtained during the assessment process. During the site visit, we found some of the policies did not reflect the daily practices of the service, for example the recruitment policy and safeguarding policy. Many documents we requested to see on site were not readily available or accessible. Recommendations from action plans from risk assessment had not been completed. Documents requested were made available after the site visit.

During our visit, the leaders were unable to show us they had a system to assure themselves of the competency and validity of all clinical staff working at the service. However, after the site visit, the service shared evidence of how they have assured themselves. The leaders informed us that the junior partners were being trained to become leaders. There were various leads assigned to different roles, but risks to patient care identified from this assessment in areas such as clinical care, safeguarding, administrative tasks management and response to patient complaints which the service had started to follow up on since the site visit.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. The service was actively involved in primary care initiatives within the primary care network. However, we found that the Patient Participation Group (PPG) was not operating effectively to support improvements in service delivery. The PPG members we spoke with indicated that PPG meetings were not organised and recorded consistently.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. Learning from incidents and complaints was not always shared with staff and discussed at team meetings. The meeting minutes seen by CQC lacked evidence that learning was consistently embedded in daily practice and recorded for future reference. Concerns identified during the clinical searches were being followed up, but the impact of this action was yet to be seen. The service worked in collaboration with other relevant stakeholders to conduct clinical research but the impact on the patient population was not yet recorded or recognised. The service had a plan to use Artificial Intelligence (AI) as a digital receptionist in the near future but had not yet implemented this. There was no evidence that Patient Participation Group (PPG) meeting minutes were recorded or there was a structure to the PPG. However, the PPG was instrumental in improving telephone access and other appointments system used by the service.