The Borchardt Medical 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 71 (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, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The practice had governance systems to support oversight and quality improvement. Staff meetings were held regularly and covered key areas including complaints, significant events and performance. Significant events were recorded, investigated and shared with staff to promote learning. Policies and procedures were available electronically, and staff understood how to report incidents and concerns. The practice used electronic systems to monitor risk assessments and track quality improvement activity.

However, governance arrangements were not always operating effectively. We found that, although a data breach had been identified and the decision not to report it to the Information Commissioner's Office had been recorded, the rationale for this decision was not clearly documented and there was insufficient audit trail to demonstrate robust decision-making. We also identified a number of environmental and safety concerns that had not been effectively monitored through governance processes, including overdue fire drills, gaps in water safety monitoring, expired consumables and the absence of a CCTV privacy impact assessment. In addition, oversight of mandatory training was not always effective, as some staff had not completed all required training. We also found out of date equipment and reagents in the medical emergency bag which was immediately removed from use. A premises reasonable adjustment risk assessment had not been completed.

Following the inspection, the practice provided evidence that action had been taken to address the concerns identified. Mandatory training records had been updated, with previously outstanding training completed and arrangements in place to complete any remaining training. The practice had also strengthened its management of a data breach by carrying out further review and risk assessment. In addition, evidence was submitted to demonstrate that water safety issues had been reviewed, remedial actions had been undertaken, and plans were in place to address any remaining actions.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service. Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations. Staff submitted data and notifications to external agencies as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.