EMC 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. However, the provider has remained the same. Under the previous registration they were rated good on 13 March 2020.This key question remains as asGood

This service scored 68 (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 practice vision and strategy, which was kept under review. We saw that staff meetings involved discussing future plans and actively sought feedback from staff. An example of this was a Physician Associate going to local mosques to speak with women about cervical screening

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. The provider included staff in discussion with us about the areas identified for improvement. They told us that they were a collaborative service and would engage with staff to ensure that the vision of the service was understood by all. For example, the provider facilitated the Physicians Associate to go to locals mosques to increase take-up of cervical screening and immunisations.

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 were knowledgeable and experienced and led the service with integrity. However, gaps in assurance systems meant leaders did not always have effective oversight of all risks.

Staff understood the values of putting people first, treating them with dignity, and working together to provide safe and compassionate care. Leaders made sure these values were part of everyday practice. The culture was open and respectful.

Staff described feeling valued and motivated in their roles, with leaders who listened and recognised their contributions. Staff told us they felt included, supported, and managers were approachable and encouraged them to share ideas or raise concerns.

Regular meetings and supervision gave staff time to reflect on their work, learn from each other, and stay focused on what mattered most to the people they supported. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service promoted an open culture, and staff told us they felt able to raise concerns. However, governance processes had not identified that the Freedom to Speak Up Guardian arrangement was not fully aligned with good practice due to a lack of independence. The Freedom to Speak Up Guardian (FTSU) role was held by a staff member within the practice. NHS England guidance is that Iintegrated Care Boards should ensure that primary care staff including GP practice staff, have access to independant FTSUG. Practices can have their own as well but the guardian should be independent of the line management chain or GP partnership so many practices use a shared, PCN, federation, or ICB level guardian because this can provides more independence for staff. We raised this with the provider, who acknowledged the concerns and took prompt action to establish an alternative arrangement with a local provider.

Evidence of the revised arrangements was provided during the inspection period. The provider had a freedom to speak up policy; however, this policy did not identify the risk of having an internal FTSU guardian which could stifle honest and open discussions by staff. The provider told us that the new FTSU guardian arrangements would be reflected in an updated policy.

We saw that staff meetings were taking place regularly, with staff able to discuss concerns, both professional and personal either in a group setting or one to one with the management team. We were told that informal discussions about patient needs occurred regularly, where staff asked for advice and guidance from senior colleagues.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, and the wellbeing of staff was supported.

Leaders ensured staff were recruited fairly and valued for their skills, knowledge, and personal qualities, regardless of background or personal circumstances. Policies and procedures supported equal opportunities, and staff told us they felt respected and treated fairly.

Training in equality and diversity was provided, and staff understood the importance of creating an inclusive environment both within the workplace and in the care they delivered. Staff said the service encouraged openness and respected individual differences, which helped build a positive and supportive team culture.

The service did not always have effective systems of accountability, governance and oversight to identify, assess and mitigate risks.

Audit and monitoring processes had not identified gaps including missing emergency equipment from the emergency medicines kit. Environmental and infection prevention and control audits had also failed to identify that a reception waste bin did not have a lid and that a stair guard was missing at one of the locations. In addition, risk assessments relating to ongoing building works were not sufficiently comprehensive, as they did not fully consider emergency contingencies or the needs of people who may require additional support.

We also found that audits had failed to identify that arrangements for Freedom to Speak Up were not fully aligned with NHS England guidance. The provider had appointed an internal Freedom to Speak Up Guardian; however, the role was not independent of the practice's management structure. In addition, the provider's Freedom to Speak Up policy did not identify the risks associated with these arrangements, including the potential for staff to feel less able to raise concerns openly. Not all staff demonstrated a clear understanding of Gillick competence. These findings indicated that governance systems were not always effective in identifying risks, maintaining oversight and driving improvement.

However, leaders responded positively to the concerns identified during the assessment and took prompt action to address them. This included establishing an alternative independent Freedom to Speak Up arrangement and updating governance processes. Staff understood their roles and responsibilities, received regular appraisals and performance reviews, and had access to relevant policies and procedures. Regular staff meetings were held to discuss clinical matters, operational issues and emerging risks, with actions recorded and shared appropriately.Partnerships and communities

The service understood their duty to collaborate and work in partnership, so services work 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, and flu and covid vaccination programmes.

The provider utilised the Patient Participation Group (PPG) to reach out to the local community to encourage attendance at the monthly support groups within the local mosque. The aim was to promote to the services they provided within the community. They used these platforms to raise awareness of issues such as the importance of immunisations and screening services and how these could impact positively on health outcomes for people.

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.

The practice had provided support to receptionist staff for them to complete qualifications in becoming a health care assistant.

However, the overall quality assurance system was not sufficiently effective in identifying risks or ensuring that learning was captured and used to drive sustained improvement. For example, clinical searches found that some people with long-term conditions, had not always received recommended monitoring within expected timescales. Audits were not always comprehensive in areas such as the environment to identify improvements in a timely manner.