Cookham 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 assessed 1 quality statement in the well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains good. We found 1 breach of legal regulations related to good governance and we have asked the provider for an action plan in response to the findings at this assessment which were: Staff were clear of their roles and responsibilities and where they needed support to increase confidence or understanding, they felt supported. Leaders and managers were approachable, supportive, and receptive to feedback from staff. Communication throughout the practice was open and transparent. There was a culture of considering risks that could affect the sustainability and performance of the practice. Where risks were identified, the practice acted in response to reduce or mitigate them. Systems and processes existed to maintain the confidentiality of data and information. Audit was used to test the effectiveness of governance systems and processes; however, this had not successfully identified processes which had not operated as expected or were not effective. These findings related to clinical governance processes and have been reported on in the key question safe.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

To ensure key messages and updates were shared across the relatively small clinical team we found the practice had combined the clinical meetings. The practice had also introduced a new software system which supported effective information sharing because if necessary, tracking and read receipts could be used. Staff we spoke with were clear of their responsibilities in relation to complaints, recording significant events and recognising safeguarding concerns and, acting on these. Where staff were less confident, they told us who they would seek guidance from. We were assured appropriate action would be taken and where needed, staff would be supported. Examples were provided which showed staff understood their responsibility to maintain confidentiality of information and staff explained how they did this. Staff we spoke with explained the complaints management process and their responsibilities in this process. Discussions with leaders demonstrated there was a culture of considering risk factors which affected the practice and those staff involved clearly explained the practices’ approach to risk assessments and oversight of risks. Although the focus of the assessment did not specifically include processes such as speaking up, management of emergency incidents within the practice and clinical supervision. Interviews with staff provided examples which showed systems and processes existed for these areas and staff understood how these operated. Where concerns were found through the assessment process, leaders and managers were accepting of the feedback and demonstrated they would engage with partners to seek advice about what to do and implement changes that would rectify the concerns. For example, the immediate response to the management of blank prescription stationary. Overall we found staff understood and could explain the governance processes that operated within the practice.

There was a culture of considering risks that could impact the practice. A risk register was maintained and there was a rolling programme of review to remove old and add new risks. All risks had control measures assigned to mitigate or manage the identified issue. Meeting minutes showed evidence of open and transparent communication. In addition to staff explaining how they maintained security of data and confidential information we saw evidence of a compliance audit where many areas were found to be 100% complaint. Where action was needed to improve, this had been completed. We found evidence of clear and effective governance processes that were operating consistently and as expected in many but not all areas. For example, we found the practice had clear oversight of financial sustainability, workforce planning and staffing levels. We also found the practice undertook succession planning which was evidenced by a restructure due to a retirement and staff resignations. We found the practice audited processes to identify performance concerns and acted where these were identified improvements. For example, this was how the new medicines safety alert protocol had been identified as necessary. However, the practices own governance had failed to identify the concerns we found in relation to the findings of the remote clinical searches, the systems and processes to ensure PSDs were authorised correctly, that blank prescription stationary was able to be tracked throughout the practice and, the decision not to stock 3 emergency medicines had not been reviewed for many years. Overall we found the practice had systems and processes which provided oversight of performance to leaders and managers and there were ambitions to improve these processes further. However, opportunities existed to further embed the auditing of internal processes, especially clinical process, to ensure best practice and guidance was followed and they were more effective.

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.