Updated 14 January 2025
Date of Assessment: 18 February 2025 to 27 February 2025
We carried out an unannounced assessment of elements of the medicines arrangements at both sites associated with Mayflower Medical Practice followed shortly afterwards by a short notice announced comprehensive assessment. We reviewed all quality statements under the safe, effective, caring, responsive and well-led key questions. This assessment was carried out to assess the quality of services being delivered both as a new registration and following concerns we had received.
Mayflower Medical Practice is a dispensing GP practice based across two sites: one in Bawtry and one in Finningley. It delivers services to 7,439 patients under a contract held with NHS England and is registered with the CQC to provide the following regulated activities: diagnostic and screening procedures, surgical procedures, maternity and midwifery services and treatment of disease disorder or injury.
The National General Practice Profiles states that around 95% of patients are of a white/British origin; with a further 1.8% of Asian origin. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the ninth decile (9 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery.
We rated the key question of safe as requires improvement. Whilst leaders often promoted a proactive and positive culture of safety based on openness and honesty, based on evidence collected at the time of assessment, this evidence did not demonstrate that this proactive and positive culture was always embedded into practice. This was because whilst systems and processes were in place to manage significant events, not all staff were aware of them, and staff feedback over time indicated that the processes for managing and responding to significant events were not always consistently followed. For example, concerns were raised with us, and we saw evidence that safety incidents relating to the management of medicines within the dispensary were not always raised, discussed or addressed. Whilst the provider demonstrated a commitment to improving the way they involved people to manage risks, this was not fully embedded into practice. Systems to manage infection, prevention and control, safe staffing and the management of medicines were not always followed. For example, some prescriptions were not signed before medicines were dispensed and handed out to patients. The service worked to safeguard people from the risk of abuse and demonstrated a joined-up approach to safety that involved the person themselves, staff and other partners in their care. This included during referrals, admissions and discharge, and where people moved between services. Facilities, premises, equipment and technology were appropriately maintained.
We rated the key question of effective as requires improvement. The service did not always maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care and wellbeing with them. They did not always plan and deliver evidence-based care and treatment to people who used the service. The service worked well across teams and services to support people. They supported people in managing their health and well-being to maximise their independence, choice and control. The service did not always routinely monitor people’s care and treatment to continuously improve it. Whilst staff told people about their rights around consent and respected these when delivering person-centred care and treatment, the provider could not demonstrate that governance and assurance systems were in place to ensure the recording of consent or the review of “Do not attempt resuscitation“ (DNACPR) decisions on patient electronic records to assure that they were still valid.
We rated the key question of caring as good. The service treated people with kindness, empathy and compassion and respected their privacy and dignity. People who used the service were treated as individuals and made sure people’s care, support and treatment met their needs and preferences. They promoted people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing. The service listened to and understood people’s needs, views and wishes. Staff responded to people’s needs in the moment and acted to minimise any discomfort, concern or distress. Leaders promoted the importance of staff well-being. Despite this, evidence did not consistently demonstrate that leaders acted in a way that promoted the well-being of their staff.
We rated the key question of responsive as good. The service mostly made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. Staff worked in partnership with other services to meet the needs of its patient population, and supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Learning from complaints was evident and staff told us about changes made as a result of patient feedback, including complaints. The ensured that people could access the care, support and treatment they needed when they needed it. Staff and leaders listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.
We rated the key question of well-led as requires improvement. The provider did not have a clear shared vision and culture which was based on transparency, inclusion and engagement. While leaders promoted compassion and inclusiveness, our assessment evidence did not align with this. The evidence did not demonstrate that leaders embodied the culture and values of their workforce and organisation. The practice had established Freedom to Speak up arrangements, however, we found staff did not always feel they could speak up and that their voice would be heard. Policies and procedures to promote diversity and equality were in place. However, based on evidence collected at the time of assessment, the provider did not demonstrate that staff were always treated equally or fairly. The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff and leaders understood their duty to collaborate and work in partnership, so services work seamlessly for people. The provider promoted continuous learning, innovation and improvement across the organisation and local system. The provider had an improvement plan in place with evidence of actions delivered. A wide range of audits were taking place which showed learning and improved outcomes for patients. The PPG spoke positively about improvements made because of their feedback. Feedback was negative in terms of leaders listening to and learning from staff feedback.
We found breaches of regulation in relation to safe care and treatment and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment. Where relevant, further commentary is provided in the quality statements section of this report.