Storrsdale 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.

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.

All staff had contributed 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, such as the projected increase in the local population over the coming years and worked 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.

Leaders promoted a culture that focused on staff wellbeing, teamwork and supporting each other. Regular meetings were held and staff told us leaders were approachable and listened to concerns and suggestions. Staff wellbeing was supported through team-building activities and wellbeing initiatives, helping to create a positive working environment.

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 had clear responsibilities, roles, and systems of accountability. However some areas for improvement were identified.

They used information about risk, performance and outcomes to support decision-making and service improvement. However, governance arrangements were not always fully effective in identifying and addressing all issues in a timely manner.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service. Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. 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. Staff submitted data and notifications to external agencies as required.

However, governance systems were not always fully effective in ensuring that actions taken were consistently documented, subject to appropriate oversight and used to support shared learning across the service. We reviewed incidents where appropriate action had been taken to manage the immediate issue; however, records did not always demonstrate that investigations had been fully completed, learning had been clearly documented or that lessons learned had been routinely shared with staff through established governance processes.

We also identified areas where governance arrangements required strengthening, including oversight of emergency medicines monitoring, aspects of recruitment documentation and legionella management arrangements.

After the assessment the provider notified us of action that had been taken to address these concerns. This included scheduling a legionella risk assessment, ensuring a DBS check was completed for all staff, and ensuring appropriate action was taken for the incidents we reviewed during the assessment.

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.