Dr S Bassi & Associates Ltd

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

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement. We found significant issues with governance and the systems for learning and improvement.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke to could articulate what they understood as the values and mission of the service. However, there was no evidence of a shared vision and strategy that was formalised and kept under review which all staff contributed to.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

Staff told us leaders in the practice was approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the primary care network.

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

Staff had access to a Freedom to Speak up guardian and open door policy. Staff were aware of how to raise concerns and were confident to speak up without fear or detriment.

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.

The service had clear responsibilities, roles and systems of accountability. Staff knew who the designated lead was for specific areas of service provision. For example, the lead for infection prevention and control or safeguarding. However, the systems to ensure good governance were ineffective. Policies and procedures were insufficient. For example, the staff induction policy was overdue a review, the staff recruitment policy did not specify a review date, and the disclosure and barring services policy was not personalised to the service, and it had no date of issue or next review date. The infection prevention and control policy was last reviewed in 2022. The business continuity plan did not contain all the necessary information to maintain all essential services during disruptions, and the plan had no review date. There was no evidence of regular staff meetings as meeting minutes were available for only December 2024 and April 2025. Staff we spoke to confirmed that meetings were not regular. The service did not have processes to evidence effective staff recruitment, induction and training. Staff appraisals and performance reviews were confirmed by the practice manager to be overdue.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes.

The service did not focus on continuous learning, innovation and improvement across the organisation. The service did not have a programme of quality improvement including clinical audit. We reviewed 1 single-cycle prescribing audit carried out by a clinical pharmacist and 1 minor surgery audit carried out by a doctor, no other audits were available. We requested the infection prevention and control audit; however, it did not provide assurances that it covered all the potential risks as it was a pre-acceptance waste audit only. The provider could not provide evidence of systems in place to seek and act on patient and staff feedback. There was no evidence of patient or staff surveys carried out other than sms messages sent out to patients to gather feedback. However, there was no analysis of the results detailing actions to improve the quality of service provided. Meeting minutes did not detail any discussions of patient feedback and there was no active patient participation group.