Ottershaw 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 change of registration with CQC. This key question has been rated as Good, however, the service was in breach of legal regulation in relation to good governance.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice 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.

There was a positive culture within the practice and staff teams worked together to treat patients with dignity and respect.

All staff had contributed to the development of the practice mission statement, and reflected their commitment to deliver high quality, safe and holistic care, with good continuity to all patients and their families.

Staff understood the needs of people who used the service and demonstrated a commitment to ensuring access to healthcare for vulnerable groups. The patient participation group feedback supported this and one member stated that ‘staff respond to patients’ emotional and practical needs with compassion and flexibility.’

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The practice 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.

Staff told us leaders in the practice were approachable and responded to any concerns raised. They modelled the values of the practice and led with integrity, openness and honesty.

Whole practice and team meetings were held regularly to ensure information and concerns were shared with all staff. Comprehensive minutes were shared for those unable to attend and urgent updates were shared through IT systems or directly to relevant staff.

Staff told us that they felt well informed and supported in their roles, and feedback received from staff and patients about leaders was very positive.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us that they had received positive responses to raising concerns to practice leaders in the past.

Staff we spoke with were aware of who the appointed Freedom to Speak Up Guardian was at the practice. We saw information displayed in the staff rest area about how concerns could be raised outside the practice if necessary.

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

Staff had completed training in equality and diversity. Policies and procedures to promote diversity and equality were in place.

Leaders explained staff wellbeing was a priority and provided examples of action they had taken to support staff and make improvements for the workforce. Learning and development opportunities were available for all staff. Staff we spoke with told us they enjoyed the social and team building events that had been held and they were well attended.

The practice had systems of accountability and governance in place, but they were not always operating as leaders intended. This meant they were not always able to identify and mitigate risk, to ensure safe patient outcomes.

Leaders and managers supported staff, and staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks.

The provider had not fully established governance processes that were appropriate for their service and this meant they were not always able to identify and improve areas of care delivery.

Processes for assurance and risk assessment were not always fully embedded, and some further development was needed. Leaders had not identified that the contents, storage arrangements and location of the emergency trolley did not fully support the safe management of emergencies. The potential risks associated with its location and set‑up had not been recognised or addressed.

Protection against the spread of infection may not have been fully effective as processes were not always being followed, and this had not been identified or acted upon by leaders. Some equipment needed for infection prevention and control (IPC) was not available or functioning correctly. Assurance processes had not identified the incorrect use of clinical waste bins. The risk of storing a wheelchair next to a toilet had also not been identified.

We also found records of staff immunisation contained gaps and risk assessments were not in place. This meant management were unable to ensure safety around protecting patients and staff from preventable spread of infectious diseases. These issues had not been identified, and leaders were not able to demonstrate awareness and insight regarding these risks. When we bought them to their attention, they were able to assure us that they would work towards rectifying these problems.

Overall, we found that leaders did not always have adequate oversight of processes, to assure themselves services provided were safe and effective. These findings were discussed with the provider during our site visit.

Following our assessment, leaders at the practice sent us details of the actions they had taken to address risks identified in staff immunisation files. They told us how these improvements to their processes will reduce the risk of these concerns arising again in future, and they explained how this will enhance oversight and assurance in these areas.

The practice 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.

Leaders had identified groups within their patient population who were at higher risk of needing support and worked with local health and wellbeing services to improve their outcomes. Ottershaw Surgery understood its importance in a village community and worked to support service users to live healthier lives. For example, by holding education events focussed on holistic care and disease prevention.

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.

Quality improvement activity was undertaken which was tailored to the patient population and their health needs. Provision of care was assessed to understand whether it was effective and appropriate to meet the needs of their patient population. This included looking at people who attended frequently, to explore whether they had unmet health and care needs that could be better supported. Results of this work also drove improvements in continuity of care for those needing to attend regularly by adding digital flags to clinical records.