Scott Road 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 service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, 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 regulations in relation to good governance.

This service scored 57 (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 vision statement on display for staff and patients. This promoted core values of the service which included respect, compassion, equality and inclusivity (towards both staff and patients). However, staff told us they had not been involved in developing the service’s vision and strategy.

Leaders told us that (since the COVID-19 pandemic) other priorities and major changes in the key staff team meant the service had not actively reviewed its vision and strategy. The service’s business plan was outdated by 5 years. This plan was still being worked towards. The provider told us they intended to review it and that they would seek feedback from staff to help shape their future aims and objectives.

Most staff told us there was a positive culture and a good working atmosphere at the service.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, and who 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.

The service had an ‘open door’ policy in place which encouraged staff to approach their direct line manager or a senior manager with any concerns.

Staff feedback was mostly extremely positive. Most staff felt supported and that senior managers were visible and approachable. A staff member told us, “I have never worked for anyone more supportive to staff.”

Although the service tried to foster a positive culture, staff did not always feel they could speak up and that their voice would be heard.

Most staff knew about the Freedom to Speak Up Guardian and how to raise a concern. However, not all staff felt if they raised a concern relating to safe care of patients that it would be welcomed.

The service had a policy in place covering ‘whistleblowing’ which gave staff a clear process to follow, as well as details of support routes available.

The service had established Freedom to Speak up arrangements with another practice so senior managers could raise concerns outside of the service if needed.

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

Policies and procedures to promote diversity and equality were in place.

The service had put adjustments in place to support staff. They ensured all staff were valued.

All staff were required to complete training on equality and diversity.

The service did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

There was no effective system in place to maintain oversight of audits and monitor any improvements based on audit conclusions.

The service did not always document or take appropriate action following safety events. There was no system in place to analyse trends of safety events to try and mitigate against recurrence of a similar event.

Staff were sent details of ‘learns’ following safety events. However, staff did not always understand the context of these to ensure effective learning and make changes to their work. The service did not have an effective system in place to ensure any learning was successfully embedded with staff.

The service did not have effective oversight of non-medical prescribing staff to ensure safe care and treatment of patients.

Managers did not always clearly record actions arising from staff performance meetings.

The service understood their duty to collaborate and work in partnership so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service utilised the additional support roles via the PCN to provide extra support for a variety of patients with more complex needs. They also utilised PCN trial models to replicate clinics for their patients.

The Patient Participation Group worked with the service to try and encourage more members and ensure representation across the local patient population.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service did not have a programme of regular audits to ensure and improve the safe care and treatment of patients.

We found that known risks had not always been acted on.

A system was not in place to ensure learning following safety events was successfully embedded with staff.

However, the service had acted on wellbeing improvement suggestions made by staff.