Abbeyview 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. We found a breach in regulation under good governance and as a result took enforcement action asking the practice to take appropriate actions within 3 months to meet the areas of improvement identified. We found a lack of oversight of systems and processes, including with significant events, complaints, risk assessments and of the environment, staff breaks were not managed in line with legislative requirements, appropriate governance and management processes were not in place for managing and monitoring when patients have a raised blood pressure and a lack of assurance around accuracy of patient records.

This service scored 50 (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 did not have a shared strategy, vision and culture. Staff meetings were inconsistent and as a result, the vision for the practice was not shared with all staff. Staff did not always feel valued. Some staff felt they had a high workload. Complaints and significant events were not managed in line with policy. The provider was recruiting additional staff however they were not in post at time of our assessment so we are unable to assess the long term impact of this. Staff were not involved in the long term strategy for the practice.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Staff did not always feel that concerns raised would be acted upon. We saw examples where there was lack of oversight from the leadership team which led to systems and processes not running effectively at the practice across multiple areas of governance and patient management.

People did not always feel they could speak up and that their voice would be heard. Staff knew how to raise concern but did not always feel their concerns would be acted upon. The practice did have an external Freedom to Speak Up arrangement where staff could contact someone independent of the practice. Staff felt a recent management change was positive for the future and took on board issues that mattered to staff. As this change was recent, it is too early for the impact to be assessed long term.

The service did not always work towards a fair and inclusive culture by improving equality and equity for people who work for them. For example, one staff group never received any breaks in the working day and this had been ongoing for some time. The practice planned to address this at the time of our assessment. A recent management change highlighted that staff did not have a place to take their break. A room was restructured to allow staff to meet at break times and this was a positive change noted by staff.

There was a lack of oversight at the practice, resulting in poor governance processes and inconsistent outcomes. They did not act on the best information about risk, performance and outcomes. The practice did not consistently manage complaints, significant events, recruitment and training to an acceptable level. During a change in management, there was no clear system in place for managing this transition and delegation of tasks to ensure systems and processes were maintained was not implemented. Meetings within the practice were inconsistent, resulting in communication between staff not always being clear. Meetings were minuted but these were not always shared. A recent change in management was viewed as positive by staff at the practice and initial changes had been seen at our visit however it is difficult to assess the long-term impact of this. During clinical searches we found discrepancies in patient blood pressure recording. Therefore, we were not assured at the accuracy of patient records and if appropriate treatment plans were in place.

The practice was keen to work within their community. They worked with external services as required. The practice had arranged a community engagement event which was well received. The event placed emphasis on highlighting conditions people may have such as asthma, COPD and mental health. They offered health checks as part of the event. They sought to engage children through a health and wellbeing themed scavenger hunt. The practice engaged with various local companies and organisations to attend the event which consisted of 24 stalls for people to engage with. The practice worked well with their PPG and had established a good relationship with new management. The practice had a good relationship with the care home they served, especially with the pharmacy team at the practice.

The service did not always focus on continuous learning, innovation and improvement across the organisation. Learning from significant events and complaints was not consistent and not always shared with all staff. Consecutive years of the National GP Survey showed similar results and there was limited evidence that the practice had made improvements to reflect in the results. The practice did evidence in house training sessions they ran but frequency was inconsistent and did not reach all staff to have widespread impact. The practice did proactively explore how they could engage with local services to impact on their population’s health and wellbeing as demonstrated by the community engagement event they organised.