Fordbridge Medical Centre

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• 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 practice 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 to requires improvement.

The practice was in breach of legal regulation in relation good governance.

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.

Leaders described a shared vision and culture. Staff described what they believed the vision was which aligned with that of the practice leaders. However, it was not recorded anywhere to ensure staff were aware of the vision of the practice. We also found that the practice did not have a clear strategy to achieve their vision, with a lack of prioritisation of actions.

There had been recent changes in the management of the practice. The practice now 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. We found that in some cases where staff had taken on additional responsibilities they had not been provided with sufficient training or supervision to ensure they were completing these roles appropriately.

Staff told us leaders in the practice was approachable and leaders in the practice described an open-door policy. One member of the management team had recently completed mental health first aid training to enable them to better support staff. Some staff told us it was too soon after the management changes to be certain that positive change was embedded and would be sustained. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

We found that leaders in the practice were responsive to feedback provided during their assessment and have told us they have already addressed some of the concerns we raised.

Leaders in the practice fostered a positive culture where patients felt they could speak up and their voice would be heard. Staff told us that leaders in the practice were approachable, although they told us this had not always been the case. Staff described a high level of recent changes where they had not always felt safe to speak up. There was a named speak up guardian in house and the practice had established Freedom to Speak up processes through the integrated care board. Staff were aware of how to raise concerns. However, some staff gave us examples of concerns they had raised, in some cases on multiple occasions, where leaders in the practice had not taken appropriate action at the time of our assessment.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There had been an extended period of change within the practice with a high turnover of staff, including those in key management roles. Both staff and leaders in the practice described this as a very challenging experience. Staff described how they tried to do their best for patients despite describing this as a challenging and unsettling time where the culture in the practice had been poor. Staff told us they could see improvements being made in culture and stability, describing new managers as approachable and they believed they would be supportive. However, some staff told us it was too early to be certain these would be sustained.

We found that improvements had been made in the last few months. However, at the time of our assessment, we found systems and processes to support good governance were not always working as intended. The practice did not always act on the best information about risk, performance and outcomes. There was a lack of management oversight of the current risks in some areas which the provider had failed to identify or mitigate. For example, insufficient action had been taken to mitigate risks identified through health and safety risk assessments and risks around infection prevention and control had not always been identified or acted upon.

We found that there was a lack of oversight to ensure all documentation was accurate and up to date, including compliance records and guidance for staff. Staff could access policies and procedures. However, policies and documents did not always reflect current practice or contain consistent, accurate or up to date information.

We saw evidence that the practice had improved their staff meeting programme to involve all staff. Staff took patient confidentiality and information security seriously.

At the time of our assessment the provider did not have a registered manager in place. The provider must have a manager who is registered with CQC as a condition of the provider’s CQC registration. The practice had failed to provide CQC with an accurate, up-to-date statement of purpose. Since our assessment the practice have told us that they are taking action to rectify this.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for patients. However, we saw examples where communication from other services had not been acted upon in a timely manner. For example, action requested on hospital discharge letter.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Leaders in the practice told us that there was no active patient participation group (PPG). However, they were planning to try and set up a PPG with new members.

The practice did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The practice carried out regular clinical audits to support improvement. However, in other areas we found opportunities for learning were sometimes missed. Although leaders in the practice were aware of some improvements that needed to be made, they did not have a documented plan to prioritise, address or review these effectively.