Emsworth Medical Practice

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 following its move to a new location. This key question has been rated as requires improvement.

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

This service scored 62 (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 and human rights, diversity and inclusion, engagement, and understanding 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. The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had developed a workforce plan for 2023–2026 to analyse and forecast workforce supply. This plan considered reception, secretary, administration, and nursing teams. It considered emerging social, economic, and political environments, alongside long- and short-term strategies, and how the PCN could provide support. The workforce plan demonstrated anticipated increases in people registered with the service over the next ten years and accounted for an ageing population. Each team was reviewed, including staff numbers, working hours, and the time taken for each work activity, with calculations made for unused hours.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

During the inspection, staff expressed mixed views about the service. Some told us they would like to see improvements in chaperone training, with a preference for this to be delivered face to face. Leaders were not aware of this preference at the time of inspection but told us it would be discussed at the next all-staff meeting. Staff also felt training could sometimes appear reactive rather than planned.

However, staff appreciated the empathy leaders showed when they needed support to manage a work-life balance. Despite these concerns, staff told us they felt valued, and teams generally worked well together. Leaders were described as visible and approachable.

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

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Individual risk assessments for staff were not consistently available where reasonable adjustments should have been recorded. A spreadsheet was used to log actions taken by the service, but it did not specify which staff members the adjustments related to or how changes would be monitored and assessed. Staff told us this approach was used because there was no private way of recording the information without making it accessible to all staff. The service had not considered any alternative ways of monitoring this information despite this issue.

Staff working with display screen equipment (DSE) are required to complete a mandatory DSE risk assessment in line with the Health and Safety (Display Screen Equipment) Regulations 1992. Evidence of individual completion was not provided, and leaders told us while staff were encouraged to complete assessments, this was not formally monitored or recorded.

Despite these gaps, we were informed reasonable adjustments had been made for staff where needed. Leaders demonstrated awareness of individual requirements, and although the spreadsheet lacked clear links to staff members, adjustments were implemented to support staff wellbeing.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate

Governance processes were not consistently embedded or effective across the service. A documented process for managing prescription stationery was not implemented as intended. Prescription pads were returned to storage without serial numbers being recorded, meaning the service could not maintain an accurate audit trail.

The service did not have effective oversight of health and fire safety. Legionella monitoring records were not maintained, with the last test completed in 2022, and there was no evidence of flushing infrequently used outlets. A fire risk assessment was completed in October 2024, but several actions due by December 2024 remained outstanding. There were no records of in-house fire drills, and CCTV signage was missing at the time of inspection. During our onsite visit, the service acted promptly to ensure appropriate signage was displayed to meet privacy and security standards.

There was uncertainty among the management team regarding responsibilities for key aspects of health and safety, including fire safety. It was unclear whether these responsibilities sat with the service or NHS Property Services. A folder provided by NHS Property Services, located at the front of the premises, contained an index outlining specific responsibilities. However, this had not been embedded into day-to-day operations nor understood by leaders.

During our onsite visit, we noted policies and procedures were not stored in a designated or centralised location. Staff also reported difficulty locating relevant documents when requested, which led to delays during the inspection. The Fire Safety Policy could not be located on site. There was also no structured system for policy review or version control. This lack of organisation and accessibility increases the risk that staff may follow outdated or incorrect procedures, potentially compromising safety, compliance, and the quality of care provided.

There was a lack of oversight of staff training and performance management. Based on the training matrix provided, 19 different training topics had not been completed by various staff, including clinical and non-clinical team members. Although staff were encouraged to complete training in advance of their appraisals, and automatic reminders were sent via the eLearning system, the leaders could not confirm how often the training matrix was reviewed or who held responsibility for booking and monitoring training.

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. Care homes supported by the service described strong working relationships and valued the continuity provided by having named GPs.

The Patient Participation Group (PPG) played an active role in supporting health education and community engagement. The PPG organised 2 to 3 health talks per year on topics such as women’s health, urology, and Cardiopulmonaryresuscitation (CPR). On some occasions, consultants supported these sessions. Events were held in local community venues at varied times to encourage good attendance. The PPG also worked with the local council to secure additional designated parking spaces at the car park next to the service.

The service worked with a local home visiting team to support housebound people and those living in care homes with regular ward rounds and named GPs.

Extended access appointment arrangements provided by Emsworth Medical Practice were available Monday to Thursday until 6.30pm, offering GP appointments. Through the primary care network, the extended access hub provided appointments with both GPs and nurses.

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. They actively contribute to safe, effective practice and research.

Learning from complaints had led to improvements. For example, the complaints procedure was reviewed and adjusted after a person was not acknowledged within the agreed timeframe. The updated process was shared with staff to ensure compliance with agreed standards. This demonstrates that the service responds appropriately to feedback and uses complaints as an opportunity to improve systems and patient experience.

The Patient Participation Group (PPG) ran community sessions to support people in using the eConsult system and help them understand how to access and navigate it. These sessions helped improve people’s confidence and digit skills, particularly supporting those who may face barriers due to age, health needs or digital literacy. This work enabled and upskilled people within the local community, helping to ensure the service remained accessible to its wider demographic.