The Hollies Surgery

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• 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 did not rate this key question. At this assessment, we have rated the key question of well-led as inadequate.

The service was in breach of legal regulation in relation to good governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice updated their organisational vision and strategy by asking staff on their views. However, we found the practice did not have leaders at all levels who were able to deliver a shared vision, strategy and culture.

There was a mixed response from staff regarding the culture within the practice. Some staff were positive and described it as open and supportive whereas other staff felt there was a closed culture and felt there was disengagement with the leadership team.

We have rated this quality statement with a score of 1 because we identified a breach of regulation in relation to good governance.

In our last assessment, we found staff were unsure on who the leaders were as roles changed often and there was a high turnover of staff. In this assessment, we found there was more clarity around lead roles and an improvement in turnover of staff. However, some staff were not sure on who to reach out to for clinical support. We found not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. Some staff told us there was a need for better communication across teams and for the leadership team to be more visible and engaged with their staff. Staff also expressed concern about a lack of formal supervision and appraisal support.

People did not always feel they could speak up and that their voice would be heard. Freedom to Speak up arrangements outside of the practice were not established.

We have rated this quality statement with a score of 1 because we identified a breach of regulation in relation to good governance.

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. However, at the time of the assessment, we could not see completed training for equality and diversity for staff.

In our last assessment, we found leaders were aware of some of the challenges the practice faced and the gaps in the risk management and governance systems. In this assessment, we found the practice had worked on some of the challenges, such as recruitment of staff, to improve services. However, staff reported it was unclear on who to reach out to for clinical support.

We found that leaders did not meet with clinical staff regularly to complete appraisals and performance reviews. Although all staff had specific roles and responsibilities the practice could not demonstrate who had oversight of all systems and processes to ensure effective care and to drive quality improvement. The provider could not demonstrate effective governance systems in place to maintain, for example, appropriate formal supervision of clinical staff and the management of safeguarding registers.

Leaders held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks; however, meetings were not regularly held with healthcare professionals outside of the practice.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. The practice met up with their patient participation group (PPG) every two months. The PPG had an active contribution with the practice who made recommendations to the practice.

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 always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

We requested evidence of quality of treatment and services had been monitored within the last 12 months, including 2 completed clinical audit cycles. The practice provided us with two clinical audits but neither had been repeated to provide evidence of improvement. The clinical lead informed us, after the assessment, that further audits were due to be started.

The practices’ complaints log lacked sufficient detail, so we did not have adequate evidence that lessons were always learnt to continually identify and embed good practice.

We have rated this quality statement with a score of 1 because we identified a breach of regulation in relation to good governance.