Aylesford 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.

We found that the service was not always providing well led services. This is because the provider could not demonstrate that governance procedures and processes had ensured safe and effective care were being provided.

Following the site visit, the provider sent us evidence of improvements they were intending to make in response to our findings. For example, implementing new policies, procedures and processes. However, these needed time to be implemented and embedded effectively.

We will review these improvements at our next assessment.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders detailed a clear vision and values for the service. This was shared with staff. Staff were aware of and understood the vision, values and strategy and their role in achieving them. 

We found that there was a clear vision and set of values, which the service acted on. The service had a realistic strategy and supporting business plans to achieve priorities. The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population. The provider monitored progress against delivery of the strategy.

Staff told us that leaders did not always support and embody the culture and values of their workforce and organisation. Staff told us that managers were generally visible and approachable and that they worked closely with staff and others to make sure they prioritised compassionate and inclusive management leadership.
 

There were clear lines of responsibility to support capable leadership. The practice had put in place job descriptions for all staff and had ensured staff were aware of their roles and responsibilities.

We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

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 with other practices in the primary care network. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They work 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. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued. For example, we saw adjustments to support staff working flexibly.

The service had clear responsibilities and roles. However, they did not always have systems of accountability and good governance, and improvements were required.

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 governance processes at the service had not ensured that safe and effective care were being provided. The assessment found concerns relating to safeguarding systems, processes and practices; complaints management; infection prevention and control (IPC) systems and procedures; medicines management; people’s needs not always being appropriately assessed and care and treatment not always being delivered in line with evidence-based guidance in the practice.

The provider had established governance processes that were appropriate for their service. However, some policies needed to be implemented and embedded. For example, clinical supervision, minor operations and histology policies. 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.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network to offer extended access, flu and covid vaccination programmes and minor procedures. Staff had made adjustments to improve coordination of their service with community healthcare services.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The practice had a quality improvement plan to help drive improvements in services.This focussed on the appointment system, medicine prescribing and people’s wellbeing.