Archived: Whitestone 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 assessed 4 quality statements from this key question. We found the provider did not have clear and effective governance processes, which supported the safe delivery of care. Copies of current and / or updated policies and procedures and audit reviews were not provided to show that staff would have clear guidance on their individual responsibilities and know who was accountable for each aspect of the service. The lack of evidence did not provide assurances that if the provider returned to the practice, they had the leadership capacity and capability to effectively drive sustainable improvements in the quality and safety of the service.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Information reviewed and documents shared by the provider showed they had identified new roles and responsibilities for staff which would be implemented to mitigate the risks identified at the inspection in January 2024. The provider was unable to demonstrate how they would assess the experience, qualification and competency of the staff in these new roles.

During our inspection in January 2024 we identified urgent risks relating to a lack of clear leadership or structure at the practice to support good governance. There were no systems or processes in place to ensure patients received safe and effective care. This included the monitoring of patients prescribed high risk medicines, medication reviews, management of long-term conditions, identification of missed diagnosis and maintaining accurate patient records. This placed patients at risk of harm.

Following our assessment in July 2024, we were not assured by our discussions with the provider that the plans for leadership and operational management would be appropriate to address the risks identified. This meant the risks posed to patients would be ongoing were the suspension to be lifted and there was no assurances that if the provider returned to the practice there would be effective processes in place to manage risks.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The evidence the provider shared with us was not detailed to demonstrate the changes put in place or planned. For example, minutes of recent staff meetings where these discussions may have been recorded were not shared. The provider had not effectively liaised with the ICB and caretaking team to understand what processes had been implemented, what improvements had been made and how they could return to practice, ensuring a smooth transition.

Evidence the provider shared with us did not demonstrate that appropriate governance processes would be established. Copies of policies and procedures were not provided as part of the evidence shared to confirm that they were updated. Information provided did not refer to any plans for staff training relevant to the new roles they would be undertaking.

The provider did not share details of how they would mitigate and manage the impact of any restrictions on their practice following the lifting of the GMC suspension and return to the performers register.

The provider was not clear about their plans to support working in partnership with local health and social care organisations and their local community.

The provider told us that there continued to be strong links and engagement with the patient participation group (PPG) and the wider community. Evidence shared to confirm this was not current and provided no evidence of recent engagement activity.

The evidence the provider shared with us did not demonstrate how they would develop and foster relationships to improve health outcomes for patients. There was no evidence to demonstrate how the provider planned to work in partnership with key organisations to support care provision. There was no evidence shared to demonstrate active liaison and open and transparent collaboration with relevant external stakeholders and agencies.

There was no evidence to support how staff would be made aware of the changes and the system in place to ensure learning was shared and improvement and innovation could be discussed. They felt confident however, that these changes would be discussed as a wider team before they were implemented. The evidence the provider shared with us was not detailed to demonstrate the changes put in place or planned.

As part of our assessment activity, we requested further evidence as we were not assured through our discussion that the risks identified would be suitably mitigated so as to protect patients from harm. We asked for an action plan and additional information however, much of the information submitted was out of date or not relevant to the concerns being raised.

Since the providers suspension on 18 January 2024 a caretaker service has been in place delivering regulated activities from Whitestone Surgery. The plans the provider submitted as to how they would deliver the regulated activities going forward should the suspension be lifted did not provide assurance that the risks would be suitably mitigated and that patients would be protected from harm. The provider did not provide evidence that a clear strategy had been developed to ensure that staff understood how improvements would be implemented and monitored.