Dunsville 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 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Dunsville Medical Centre 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.

Staff had opportunities to contribute to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy.

The service was aware of local challenges which affected their service and were working 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 to confirmed that there was a positive culture in the practice, that they liked working for the service, that there was a good working atmosphere and that they felt their views were listened to and acted on.

Equality, Diversity, Inclusion and Human Rights training was mandatory for all staff and although some staff were not up to date with it, the provider was monitoring completion.

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 acted on information relating to risk, performance and outcomes and shared information securely with relevant external agencies when appropriate. Staff demonstrated a clear understanding of their individual roles and responsibilities, and leaders held regular team meetings where emerging risks, incidents, complaints, and opportunities for improvement were discussed. Actions arising from these meetings were clearly documented and shared with staff. Staff told us that learning from significant events, incidents and complaints was communicated effectively. Staff also demonstrated a strong awareness of confidentiality and information security requirements and understood their responsibilities for protecting sensitive information and submitting required data and notifications to external agencies. Leaders were described as visible and approachable, and staff reported feeling supported by both their line managers and senior leaders. We also found that policies and procedures were up to date and reflected current guidance. In addition, staff told us that the service had improved since the appointment of a new practice manager in March 2026.

However, governance arrangements were not always effective. The provider had not consistently implemented robust systems and processes to provide assurance that the service was operating safely and effectively. As highlighted elsewhere in this report, we identified gaps in oversight relating to training, recruitment and infection prevention and control. Although staff reported having sufficient guidance to carry out their roles, the provider was not always able to promptly locate documents requested during the assessment to demonstrate compliance and effective oversight. In addition, staff told us that appraisals and performance reviews had not been completed regularly and that some had not received an appraisal for a considerable period, although the provider had scheduled appraisal meetings for August and September 2026. These findings indicated that responsibilities, systems of accountability and governance processes were not always sufficiently embedded to ensure consistent oversight across all areas of the service.

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.