Cumberland House

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 Regulation 17 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. Staff and leaders understood the challenges and the needs of people and their communities.

The service had a clear vision statement, ‘to improve the health, well-being and lives of those we care for’. The service’s vision statement was ‘to work in partnership with our patients and staff to provide the best primary care services possible working within local and national governance, guidance and regulations’. The vision statement was currently under review, and both staff and stakeholders had been asked to contribute their thoughts and ideas.

The service was aware of local challenges which affected their service and worked with partner agencies to identify additional services 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. Leaders described the culture of the service as open and engaging which was reflective of the discussions we held with staff. Staff told us they felt supported to raise any concerns which they knew would be listened to and acted on. Staff told us they enjoyed working at the service and staff were supportive of each other.

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 act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders did not demonstrate they acted on the best information about risk, performance and outcomes, due to the lack of oversight of safe working practices, staff recruitment, training and documentation of clinical supervision. Systems were not in place to maintain the security of or for tracking prescription stationery throughout the practice. Relevant risk assessments had either not been completed, or not reviewed and updated, and there was limited evidence to support when risks had been identified and mitigating action had been taken. Safe recruitment procedures were not always followed, or staff vaccinations maintained in line with current guidance. Although clinical support was available for non-clinical and salaried GPs, clinical supervision of consultations and prescribing was not formally documented. Systems to monitor compliance with mandatory training were not always effective, as not all staff had completed the required training.

The provider told us as part of succession planning the practice manager role had been reviewed and changed to 2 distinct roles of business manager and operations manager. This change helped support the development of the operations manager in their new role. Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff.

At the time of our assessment, the practice’s CQC registration was not up to date, due to the need to remove a registered manager. This was brought to the provider’s attention in addition to the requirement to display the current CQC rating within the premises

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.