Cranleigh Gardens 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 has changed to requires improvement.

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

This service scored 62 (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 unaware of the service’s vision or strategy but felt there was a positive culture. The service told us it was aware of this and planned to review the service’s vision and strategy with all staff.

The service was aware of local challenges that affected the population it served, including a large proportion of people who spoke English as a second language.

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 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, however, these were not always effective in maintaining oversight of service provision and, in some areas reviewed during this assessment, appropriate processes were not in place.

For example, actions relating to electrical safety had not always been completed. Actions identified to mitigate infection prevention and control risks in relation to the Legionella risk assessment had not been addressed. The service did not have an effective recruitment process to demonstrate all required pre-employment checks had been completed. There was also no effective process to evidence staff were appropriately vaccinated. Staff had not completed all training identified by the service as mandatory.

During the onsite visit we found printers containing blank prescription stationery in multiple rooms, and these printers were not secure. We also found boxes of blank prescription forms stored in unlocked cupboards in 2 rooms and a printed prescription containing a person’s personal information left on a printer. Although these rooms were locked at the time of inspection because staff were on a break, and we were told there had not been any reports of missing prescription stationery, leaders acknowledged this did reflect the service’s expected processes for managing prescription stationery. The service took action to rectify some of the issues we identified following our onsite visit. However, some actions remained outstanding, and newly implemented processes required time to embed.

However, all staff we spoke with were clear on their individual roles and responsibilities. Staff could access relevant policies and procedures, which were kept up-to-date and reflected latest guidance. Leaders held regular meetings with staff to discuss emerging risks and opportunities for improvements. Actions arising from these meetings and shared these with staff. Staff took confidentiality and information security seriously, including verifying people’s identity during remote consultations. The service 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.