Arran 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, fair culture

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good

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.

The service had a shared vision of providing patient centred care. All staff understood challenges and the needs of people and their communities.

The practice collaborated with partner agencies to address current and future challenges.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were approachable and listened to any concerns raised.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They 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. Leaders supported staff develop professionally whilst working at the practice.

The service mostly 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 performance and shared this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

However, we found that oversight of some quality assurance and governance processes required improvement. For example, during the assessment we found that while risk assessments relating to the building had been completed or a date for their completion had been arranged, they were overdue and had not been repeated by their review date.

We found that processes to ensure that all patients received appropriate monitoring and reviews in line with guidance, required improvement. We discussed this with the management team, who took immediate action following the assessment to improve their processes.

We also found that processes to monitor the quality of record keeping required improvement.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and referred patients to specialist services as needed.

The provider worked with other practices within their primary care network (PCN) to offer extended access and flu and covid vaccination programmes. The PCN arrangements had recently changed and the practice was still in the process of working with the other practices to re-establish these services.

The practice worked with other services to offer more specialist care for example using an app to provide new opportunities for their patients to self-manage their muscle or joint condition as soon as they engaged with the practice.

There was an active patient participation group. Representatives we spoke with told us the meetings were extremely helpful. They gave patients the opportunity to share their feedback. Practice staff listened and responded appropriately. From information we reviewed we saw that staff were actively trying to increase the membership of the group so that more feedback could be obtained and further improvements made.

The service focused on learning, innovation and improvement across the organisation and local system.

The service discussed and learnt from complaints and incidents.

The practice had an audit programme and there was evidence of some improved outcomes. Although, we did identify that not all audits led to improved outcomes or that action plans were always implemented.

The practice had taken steps to improve access. From data we viewed we saw that call waiting times and call abandonment rates were very low.

The practice had a quality improvement plan in place to help drive improvements in services. All staff were encouraged to put forward their ideas to improve.