Lytham Road Surgery

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 requires improvement.

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

This service scored 61 (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 in place. They had vision and mission statements in place which staff were aware of and demonstrated them in their work.

The practice had a business development plan in place and a vision for what it wanted to achieve in the coming year. This set out the steps it wanted to achieve to enable sustainability and build upon aims to provide high quality healthcare to their patients. They also had an improvement programme in place which aimed to “enhance patient care, streamline operations, and improve staff satisfaction through a structured, measurable improvement programme”.

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.

Staff told us leaders in the practice were approachable and responded to any concerns raised. They provided examples of support provided and how managers involved them and listened to their ideas. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked together and with organisations and commissioners and were engaged in the development of primary care services within the local area.

Although we found areas of concern during the inspection, leaders were quick to address them and implement solutions to the issues raised with them.

The practice had a Freedom to Speak Up (FTSU) policy in place, this provided a local medical committee representative as the FTSU guardian. The service promoted a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns, contribute ideas and give feedback and we saw examples where staff had done this to positive effect.

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. 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 disabled staff were in place. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff.

The service had clear responsibilities, roles, and systems of accountability. However, systems were not always in place to enable them to manage and deliver high-quality, sustainable care, treatment and support.

They did not always employ tools to extract the best information about risk, performance and outcomes, to enable them to understand their own issues and how they could improve.

The provider had not established governance processes that were appropriate for their service. Managers met with staff regularly but there were some staff who had incomplete appraisals and performance reviews. There was a lack of oversight of staff competence as there were gaps in managing clinical supervision and support as records were not kept and this was informal. There was a lack of record keeping regarding retention of key information relating to recruitment records, induction records and confidentiality agreements. Record keeping in relation to prescription security did not provide adequate assurance of their safekeeping and protection from misappropriation. Record keeping in relation to DNACPR was incomplete and ineffective. The practice use of flags and alerts for vulnerable patients was inconsistent and unreliable. Systems to oversee workflow and ensure this was processed in an appropriate and timely way was not in place. Systems to support effective monitoring of patients on high-risk medicines and based on safety alerts was not effective and this led to a lack of assurance that best practice and recommended guidance was being followed.

However, leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

Following the inspection, the practice took steps to improve the areas of concern and stated they would work to improve governance processes.

The service understood their duty to collaborate and work in partnership, so services worked 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. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The service did not always have systems and tools in place to support continuous learning, innovation and improvement across the organisation. They did not always proactively identify areas of concern or area where they could improve, due to an absence of quality assurance and performance measurement processes. They would react if an issue arose but did not undertake continuous monitoring of their processes to ensure they were working effectively. They did not actively contribute to safe, effective practice and research through an established annual clinical audit programme.

The practice did not have an effective quality assurance process or quality audits in place. We asked the practice to provide us with evidence that the quality of treatment and services had been monitored within the last 12 months, including 2 completed clinical audit cycles. The practice was unable to provide us with such because they did not have one in place. They did undertake an audit of cases where a patient ‘did not attend’ (DNA) their appointments. They produced a report, including statistics, and promotional material to help reduce these numbers and placed signage around the patient waiting areas about this. The practice had started to undertake quality audits on clinical documentation processing and coding, but there were long gaps between audits and it appeared to have been discontinued. The practice did not have a system of oversight or audit of clinical consultations, record keeping or prescribing for clinical staff, including advanced care practitioners.

However, the practice had worked hard on improving access, by increasing the number and range of appointments available and increasing the number of GP appointments, as they saw this as the gold standard. The practice acted on complaints and incidents, investigated them and learned lessons from these to reduce the chances of recurrence.

Following the inspection, the practice stated they would work to implement a clinical and non-clinical audit programme.