Scott Arms Medical Centre

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

At the last inspection we found the practice did not have fully embedded governance systems to ensure risks were identified, monitored and acted on. At this assessment we found governance processes still required improvements to mitigate risk and assurance systems needed regular reviews to provide assurances that all processes were in place. The merger of the 3 practices into 1 partnership had now been fully embedded and the leadership team maintained regular communication with the team. We found that there was leadership in place and the practice had designated roles for areas of accountability, however we found that there was uncertainty within the leadership team of who had responsibility for certain roles and how work was shared between the management team.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Due to a number of staff leaving in recent months, the leadership team had organised an independent culture review with staff to identify any potential concerns about working at the practice. At the time of the onsite assessment staff were aware of the upcoming review and were being encouraged to take part. Staff we spoke with told us they felt supported by the leadership team and felt able to raise concerns without fear of retribution. There was an open culture and the leadership team were approachable. Regular meetings were held with staff and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve. The practice had a realistic strategy and were reviewing their supporting business plans to achieve sustainability. There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian.

The CQC had received a number of whistleblowing concerns about the culture at the practice and the treatment of staff. We spoke with a range of staff on the day of the onsite assessment and staff described the practice team as supportive and the leadership team were visible and approachable. Leaders understood the challenges to quality and sustainability and had reviewed their business plans to ensure there was capable and effective leadership. There was a team of managers, however roles and responsibilities were not clear and we found there was no appropriate oversight and supervision to ensure staff had completed training relevant to their role. We were told that permanent recruitment remained challenging, with a shortage of practice nurses. However there were processes in place to ensure long term locum arrangements were in place to support the practice and mitigate risk. Lead roles for accountability had been reviewed further and the leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population. On speaking with staff we found there was limited opportunity for development as part of succession planning. There was evidence to demonstrate that when a role had become available this had not been advertised amongst the staff to ensure fairness and equal opportunities for all staff to apply. The practice was working with the primary care network on an access project to review resources and improved ways of working. This model supported the practice in their improvement plans and sustainability.

There were regular meetings held with staff and there was a freedom to speak up guardian in place. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve.

We spoke with a range of staff on the day of the onsite assessment who told us they felt comfortable in speaking up and the leadership team were approachable and listened to their concerns. Staff meetings were seen as positive with opportunities to share learning and discuss any issues as a team.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue.

We were told that there was an emphasis on the safety and well-being of staff, and they had put plans in place to recruit additional staff further to increase capacity and resources. Staff told us they were treated fairly and there was an open-door policy. We found that due to the lack of organisation and supervision of staff training we were unable to gain assurances that staff had completed equality and diversity training. There were policies and procedures in place for the safe recruitment of staff, however we found these were not followed and identified gaps in recruitment which included induction, DBS and up to date checks of clinical registration. Other policies included equality and diversity, bullying and harassment, grievances and the race equality policy. Staff had access to regular appraisals, one to ones, coaching and mentoring, clinical supervision and revalidation. We reviewed a random sample of appraisals and found that they lacked evidence of staff performance, development and training needs. This was further supported by comments received from staff on the lack of opportunities available for training. We were told there was an induction process in place for newly appointed staff, however we found limited evidence to demonstrate there was an effective system in place to ensure all staff completed a thorough induction.

We found governance processes needed strengthening to mitigate risks. These included following practice policies for the health and safety of both staff and people. For example: A number of staff had left the practice recently, however access codes to internal doors had not been changed following the departure of staff. Cleaning schedules were in place; however these had not been completed and there was no system in place to monitor that cleaning had taken place. Hazardous substances risk assessments were not in place to reduce the risk of exposure to substances and ensure risks were mitigated. Staff told us that practice policies were accessible, and they were clear about their roles and responsibilities and felt supported by the management and clinical team. We were unable to gain assurances that all newly appointed staff had completed an induction and we found that staff training had not been monitored to ensure all staff were up to date with training relevant to their role. Staff told us there were limited opportunities for development to improve their job skills. At the last inspection the provider failed to undertake effective quality and risk monitoring and we found some of the systems in place to be ineffective, this included the management of people on high risk medicines and safety alerts. During this assessment we found improvements in the management of medicines, however the process for managing safety alerts still needed to be improved to mitigate potential risks. A business continuity plan was in place which gave guidance to staff for the preparation of major incidents. There was a management team in place, but on speaking with the managers we found there was a lack of awareness of who had responsibility for certain roles within the practice.

Leaders told us they worked with stakeholders and the local community. The practice was part of a primary care network (PCN) which provided enhanced services to people. The PCN met regularly to deliver services to meet people's needs and to support care provision and service development. Leaders told us they hadn't got a patient participation group (PPG), however they had tried to encourage patients to join. Information on how to join the group was available in the patient waiting area and also on the practice website. Due to the increases in demand the practice were working with the primary care network and other stakeholders on an access improvement project to ensure resources were planned and met the needs of the service. There were processes in place for partnership and community engagement. For example, regular meetings were held across the primary care network to deliver joined up care and to share good practice and learning. In addition, the practice held regular practice and clinical meetings to collaborate effectively and make improvements in people's care and treatment.

There were regular practice meetings being held with staff with standing agenda items to share learning and practice developments. We saw evidence to demonstrate that the outcomes from significant events or complaints, were shared with staff to promote learning and mitigate future risks. Feedback from complaints, online comments and the GP national patient survey concerning access had been acted on with the introduction of a power hour for peak time at the practice where all available staff would answer phones to minimise waiting times and increase patient satisfaction.

We found that processes were in place and the practice had carried out a number of targeted quality audits and used information about care and treatment to make improvements. Information provided by the leadership team demonstrated they planned educational events for people covering health topics, such as dementia, prostate cancer and menopause.

Staff told us that they were not given opportunities to learn and further develop within their roles. We also found that training deemed mandatory by the practice was not being completed by staff and there were no processes in place to oversee that staff completed training relevant to their role.