Cheddar 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 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.

The service was in breach of legal regulation in relation to good governance.

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. However, some staff told us they were not aware of the vision or strategy of the service but felt there was a good culture.

The service was aware of local challenges which affected their service, such as the increasing age and frailty of the local population over the coming years and worked with partner agencies to address these challenges.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

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 service did not always have clear responsibilities, roles, 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 service had governance processes, but these were not always effective to maintain oversight of service provision and in some instances, processes were absent in relation to the quality statements we reviewed during this assessment. For example, actions to mitigate infection prevention and control risks had not been taken in relation to legionella monitoring, the presence of carpet in a clinical room and the consistent labelling of sharps boxes in line with national guidance. The service did not have a recruitment policy and there were gaps in pre-employment recruitment checks. Not all staff vaccination records were in line with national guidance. The service took immediate action to rectify these issues following our onsite visit, but these were newly implemented and required further embedding.

However, all staff we spoke with were clear on their individual roles and responsibilities. Staff could access all required policies and procedures, which were kept up-to-date and reflected latest guidance. Leaders regularly met with staff to complete appraisals. Leaders held regular meetings with staff. Leaders recorded actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously. 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.