Blake House 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 assessed all quality statements in the well-led key question. At our last assessment we rated this key question as good. At this inspection we rated this key question as requires improvement.

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation, and promoted an open and fair culture.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. There was not a culture of continuous improvement. However, leaders were visible, knowledgeable and supportive. Staff felt encouraged to give feedback and were treated equally, free from bullying and harassment.

We found a breach of the legal regulations in relation to good governance.

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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Leadership developed the service’s values and strategies. However, staff told us they had not been involved in developing these.

Evidence showed policies were not effectively being reviewed and updated to reflect the changes in the service. For example, some policies did not reflect the current practice manager or name Blake House Surgery as the service provider.

However, staff told us there was a positive culture, a good working atmosphere at the service and there was an open-door policy where they could access and speak openly to leaders. They felt listened to by their leaders.

Regular meetings kept staff up to date with any changes.

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.

The service had a registered manager in post as well as 1 clinical and 1 non-clinical partner. Staff feedback collected by CQC was mostly positive. Staff told us they were well-supported by leaders who were visible and approachable. They told us leaders supported them in professional and personal matters and they felt valued and listened to.

The process for recruitment records was not consistently maintained. For example, non-clinical staff files did not contain immunisation records. Certificates and qualifications for clinical staff were not kept on file for all staff. These are part of schedule 3 under fit and proper person requirements.

The service provided an induction for new staff which is signed off by the practice manager. However, some staff said they had not received a formal induction.

The service had established Freedom to Speak Up (FTSU) arrangements but staff members’ knowledge of this arrangement was inconsistent as many did not know how to raise concerns or how to contact this service. However, staff felt confident to raise concerns with their managers and leaders.

The service had a staff handbook available which advises how staff can make a complaint or raise concerns about bullying or harassment. We saw posters on notice boards containing contact information for FTSU.

The service had a policy for FTSU embedded within a whistleblowing policy. The whistleblowing policy was updated in 2024 to reflect changes made to the FTSU service. However, the policy had not been reviewed appropriately as it made reference to a previous manager and did not specifically mention the name of the service and not all staff had completed training on FTSU.

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

We saw an example of workplace adjustments to support different needs. Staff gave examples of reasonable adjustments the service had made to support them both at work and in personal circumstances.

Some staff had access to training around Equality, Diversity and Inclusion to help them understand about protected characteristics, bullying and harassment. However, it was inconsistent as not all staff had access to or had completed this training.

The service did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. There was no effective system in place to maintain oversight of audits and monitor any improvements based on audit conclusions. There was no system in place to analyse trends of safety events to try and mitigate against recurrence of a similar event.

The service shared learning from safety events during meetings with staff. However, they did not have an effective system in place to ensure any learning was successfully embedded.

Managers met with staff annually to complete appraisals and staff felt supported. However, not all staff were clear about their role and responsibility.

The service did not have established governance processes appropriate for their service. They did not have effective oversight of staff to ensure safe care and treatment of people by failing to undertake clinical supervision. The service had policies and procedures. However, some had not been reviewed since 2020. Regular review of policies would ensure information contained was relevant and up to date

However, staff took confidentiality and information security seriously. All staff had completed relevant training around information governance.

The service understood their duty to collaborate and work in partnership so services work seamlessly for people. They shared information with partners.

The service held monthly multi-disciplinary meetings that were well attended by community teams.

The service utilised additional support via the local primary care network (PCN) to provide extra support for a variety of people with more complex needs. The service’s patient participation group (PPG) worked with the service to encourage more members and ensure representation across the local patient population. At time of assessment this was an ongoing request.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The service did not have a programme of regular audits to ensure and improve the safe care and treatment of people. A system was not in place to ensure learning following safety events was successfully embedded with staff. However, staff said they felt encouraged to put forward ideas for new ways of working.