Mayflower Medical Practice

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 rated the key question of well-led as requires improvement.

The service did not have a clear shared vision and culture which was based on transparency, inclusion and engagement. While leaders promoted compassion and inclusiveness, based on evidence collected at the time of the assessment, this 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, this evidence 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. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. The service promoted continuous learning, innovation and improvement across the organisation and local system. They 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.

This service scored 54 (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 and culture which was based on transparency, inclusion and engagement.

The leaders at the practice spoke positively about future plans, their direction and the improvements that had been made and were planned. We saw multiple examples of improvements since the provider’s registration. They told us they did not have a business plan. Various action plans were provided. They understood the challenges and the needs of people and their communities. They told us they were working with staff to introduce changes and appreciated the challenges that change potentially had on staff. Staff demonstrated a commitment to providing good patient care. Staff described mostly good relations within teams, but said relationships were not always as good with leaders.

Based on evidence collected at the time of assessment, this evidence did not demonstrate that leaders ensured a shared direction and culture. Concerns around the leader’s actions and their lack of a positive, compassionate, listening culture that promoted trust and understanding were raised with us. Most of the feedback we received described communication as poor. Actions of leaders were described as non-inclusive. Some feedback we received raised concern about the impact this was having on staff.

While leaders often promoted compassion and inclusiveness, based on evidence collected from people directly and from our observations at the time of the assessment, staff feedback did not align with this. The evidence did not demonstrate that leaders always embodied the culture and values of their workforce and organisation. When issues were raised, we found examples of these being acted on, staff being supported and changes introduced but staff also told us of examples where concerns and issues were dismissed, or their importance disregarded. For example, concerns regarding staffing in reception, emergency medicine location and medicines dispensing arrangements. We received feedback and observed an environment where some staff were reluctant to speak out either because they were not listened to or because they feared the outcome. We observed fearful staff. Some staff said leaders were not always approachable, and communication was poor and at times a blame culture reported. We found significant decisions were not always discussed or shared with staff before they were implemented. Some staff described a closed culture was exhibited with an authoritarian approach.

Whilst staff attended regular meetings with leaders, we were told agendas were often not followed and dictated by leaders and the approach to addressing known issues was not always managed compassionately and inclusively. Most of the feedback we received as part of the assessment process raised concerns regarding the capability of leaders, as they were perceived to be stretched too thin, lacking presence, and unwilling to listen or accept support. After the assessment the provider provided us with statements from some staff. The statements indicated the provider had approached some staff members to give statements about their experiences of working at the practice and with the leadership team. All statements were positive.

The provider informed us they were applying to leave their current Primary Care Network (PCN) so they could join a PCN with the provider’s other two practices.

The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns. However, our assessment evidence did not demonstrate that all staff always felt they could speak up and that their voice would be heard. Some staff told us they sometimes felt belittled and were not treated fairly and their welfare was not taken into consideration when decisions were made.

The practice had a diverse workforce in place. Policies and procedures to promote diversity and equality were in place. Almost all staff had completed equality, diversity and inclusion training as well as bullying and harassment.

However, our assessment evidence did not demonstrate that staff were always treated equally or fairly. For example, we were told of multiple examples where staff’s circumstances were not taken into consideration when decisions were made and were not involved in significant decisions or given opportunities to be involved. We were told they were not always listened to, which impacted staff well-being. After the assessment, the provider sent us some examples of correspondence with staff to demonstrate where people’s circumstances had been taken into consideration and adaptions made.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. There was evidence of new governance arrangements in place and a commitment to improve oversight from the evidence we gathered. However, this was not fully embedded into practice and was not in place in some areas resulting in the issues identified during the assessment. These are referenced in the key questions throughout the report.

We were concerned about the leadership presence at both sites of Mayflower Medical Practice and the scope of responsibility for leaders, specifically the provider and the practice manager. Examples to demonstrate their lack of presence and availability and the impact this was having on staff were found. CQC also experienced several times the inability to contact the practice manager or the lead GP in the run-up and during the assessment. On one occasion when the CQC had made contact with the provider by telephone, we were informed that no managers were available that day. We were also concerned from evidence collected about the conduct of leaders and the way they treated staff or responded to staff raising issues, concerns or suggestions.

During the assessment, we found paper records were not always stored securely and observed a smartcard left in a computer. Whilst the provider informed us that one person had completed a refresher in data security, the provider had not ensured their arrangements for confidentiality of data and records were consistently secure.

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

The service promoted continuous learning, innovation and improvement across the organisation and local system. They had an improvement plan in place with evidence of actions delivered. This varied from introducing audits to increasing patient appointment times. We viewed a wide range of audits which showed learning and improved outcomes for patients. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. The PPG spoke positively about improvements made because of their feedback. We also saw in other records where issues had been identified, and changes introduced. However, we also found that known risks had not always been acted on or acted on in a timely way. For example, concerns were recorded in meeting minutes made available to us about the dispensing arrangements as far back as early 2024. Other issues are referenced in the key questions throughout the report. Feedback was negative in terms of leaders listening to and learning from staff feedback.