The 157 Medical Practice

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 practice’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture.

This was a focused assessment, which meant we did not assess all quality statements. Our rating is determined from the findings of both this assessment and our previous assessment. At our last assessment, we rated this key question as outstanding and, at this assessment, this rating has changed to good. The updated quality statement scores have been issued where relevant.

This service scored 87 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice 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 practice’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The practice was working towards a merger with a technologically advanced practice, planned for later this year; however, this had been put on hold due to changes within NHS England and the Integrated Care Board.

Staff and leaders actively promoted equality and diversity. All staff we spoke with told us they felt very supported by both the GP partners and the practice manager and felt able to raise concerns and suggestions for improvement. Staff reported feeling listened to and described the team as supportive and cohesive. They spoke highly of management and the support provided and consistently described a positive and happy working culture.

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 practice did not always 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. We identified some shortfalls in health and safety, recruitment, mandatory training and IPC.

The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their practice however, leaders needed to make some improvements.The provider did not have effective governance systems in place to ensure appropriate oversight of key risks and compliance areas. We identified gaps in systems for monitoring mandatory training, as some staff were not up to date, and mandatory training certificates submitted after the inspection were dated following the on-site visit.Systems to record and monitor the staff recruitment process also required strengthening. Although the practice had a fire risk assessment in place, leaders had not completed several immediate actions identified within it. Following the inspection, the provider took steps to improve governance and provided CQC with updates to evidence the actions taken.

Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. Staff could access required policies and procedures, which were kept up-to-date and reflected latest guidance. Leaders held regular meetings with staff, leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations.

The practice produced monthly newsletters to keep staff informed and updated on key developments, achievements and wellbeing initiatives. The practice introduced an ‘Employee of the Month’ initiative following feedback from the staff survey to recognise staff contributions. Regular team events and social gatherings were also organised, which staff said helped build positive working relationships contributing to a positive and inclusive working environment.

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.