Colney Hatch Lane 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 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.

The scores for the quality statements not assessed as part of this key question are based on the previous inspection rating for well-led for the previous provider of services at this location.

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 leaders had a shared vision and strategy. This was based on compassionate, high-quality patient-centred care being delivered in a modern, efficient and personalised way. The values and strategy had not been embedded thoroughly within the service, as some staff members told us that this vision and strategy had not been discussed and developed with or communicated to them.

The service had leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the values of their organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. Some members of staff told us that leaders did so with integrity, but not always with openness, honesty and inclusiveness.

The service told us that it was aware of projected changes in the local population and was working with partner agencies in preparation to address any future challenges. We saw the leadership team worked collaboratively with other GP practices in the primary care network and were engaged in the development of primary care services within the local area.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

People did not feel they could speak up and that their voice would be heard.

There was no evidence that the service had established Freedom to Speak up arrangements with other GP practices in the primary care network. There was no evidence that the service had its own Freedom to Speak Up Guardian if they had concerns. Staff were aware of how to raise concerns, but from our discussions with some staff members, not all staff felt they could so confidentially and without negative feedback.

Not all members of staff spoke positively about the service leadership/management and the implementation of change at the service. Some members of staff said that the service leaders were approachable and listened to concerns raised, but there was limited feedback to staff regarding what had been done by the service leaders/management to address concerns raised.

The service had a whistleblowing policy. Service leaders/management told us that there was an open-door policy for staff.

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 this key question for the previous provider for this location. The previous provider of services at this location is a partner at this service

Since our last inspection of this location, the location service provider has moved from being a sole provider of services to being part of a partnership. In addition, there had been a period of change within the service relating to staff, including a change in service management.

Staff and leaders in the service described this as a challenging experience, but that focus remained on the delivery of quality care to patients. Service leaders spoke with us about sustainability of the service which included adapting staff roles to meet patient and service needs. Staff told us of changes that occurred to the way that the service worked, without any consultation or discussion with members of staff the changes would affect.

We found systems and processes to support good governance were not always working as intended. The service did not always act on the best information about risk, performance and outcomes. There was a lack of management oversight of the current risks in some areas which the provider had failed to identify or mitigate. For example, not all staff files we reviewed had all the required information that we would expect. DBS checks were not present in all files, as well as a lack of references for staff appointed to their role within the last 12-18 months.

There was a lack of oversight of the day-to-day work of clinical staff who were not general practitioners. We spoke with the service providers about this and asked them how they assured themselves that the work undertaken by these clinical colleagues remained within their remit. We were told that these colleagues would have ad-hoc discussions with the clinical service leaders (GPs), if they came across a clinical situation that they were unsure of. Following our site visit and clinical records review, the service provided us with three sets of review and debrief session minutes (including one for a date in the future) for one member of staff. Clinical meeting minutes we viewed were not detailed, providing no in-depth descriptions of what was discussed.

Similarly, there was no evidence of formal appraisals for non-clinical staff. Service leaders told us that this had not occurred, and this was verified by members of non-clinical staff we had contact with.

We did not look at Partnerships and Communities during this assessment. The score for this quality statement is based on the previous key question ration for Well-Led for the previous provider. rating for Well-led for this location.The previous provider of services at this location is a partner at this service

The service undertook quality improvement activities and was involved with local and national primary care.

The service leaders focused on learning, innovation and improvement across the service and local systems. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The service leaders had embraced the use of automated online tools to assist in their vision for compassionate, high-quality patient-centred care being delivered in a modern, efficient and personalised way. This included replacing existing document management and workflow systems with an integrated platform which provides the service with an improved summarising, document handling and electronic filing system, using online tools to assist in the management of reviews for patients with long-term conditions and the use of Accurx for assisting with the triaging and identification of patients with a clinical priority.

The service leaders told us that by employing these tools, they have been able to free up time and be able to have more time to interact with patients and to refine internal clinical and administrative systems.