Bethany 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 75 (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. The service was aware of local challenges which affected the service, such as the projected increase in 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.

All staff we spoke with felt positive about working at the service. They described good teamwork and a service that was clear on its function to work in the interests of patients and providing the best patient experience they could. Regular meetings were held for clinical and non-clinical staff. Members of the team told us that communication was effective, and they felt included in decisions about the service.

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 had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. For example, practice meetings were held, and discussions took place about performance and operational pressures. Clinical audit results were discussed in weekly clinical meetings to share learning and agree 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; however, several had not been updated by their review dates. The management team were aware of this and had begun updating them before our assessment.

The service used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data and records. Staff took patient 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.