DeMontfort 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.

We were concerned regarding systems and processes in place to ensure effective monitoring of patient data that was being transferred to external companies. The provider however submitted assurances following inspection which addressed questions we had raised. This breach of regulation was then removed from the report.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement. This is due to some gaps in governance arrangements which were found during the inspection as well as a lack of clarity around processes between the provider and the location.

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 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.

Whilst there was a vision and strategy for Willows Health Ltd, we did not always see that this was happening within the practice. Leaders were not always aware of what was happening with the practice and when things had been raised to them, it is not always clear action had been taken.
The two layers of management for the practice, both site level management and provider level management, was not always working effectively and was creating a negative workplace culture. For example, we found that risks had been highlighted to the practice manager who had escalated these to the provider and senior managers, however they had not been addressed, such as the backlog of summarising and lack of administration staff. The lack of cohesion within the management also impacted on staff wellbeing.

The service 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us they felt supported by local management and felt able to raise concerns. Due to the model of the provider, staff were not always aware who the management of the Willows Health ltd were.

We saw that management of the provider were dedicated to improving patient care locally and had implemented initiatives to better patient care.

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

Whilst there was appointed staff members of the Willows Health Ltd to raise concerns to, some staff reported they would not feel comfortable raising concerns to someone who they did not know and were part of the managing team.

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.

Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found gaps within some governance arrangements such as handling complaints and significant events and ensuring risk assessments provided assurance that risks had been identified.

We were concerned regarding how effective systems and processes around patient data handling were. This included how data was safely transferred to external companies who supported the practice with back-office administration work. The provider gave assurances following the inspection that processes and systems were in place for data handling.

Responsibilities of staff were not always clear such as if complaints were dealt with by the site manager or the provider. We saw examples of risks being raised with no clear actions being taken by management, such as the backlog of summarising patient records.

Policies that we reviewed as part of the inspection were not always in line with what was happening at the practice and often contained incorrect information.

There was a process in place for regular staff check ins and appraisals however many of the practice staff were new at the time of our assessment.

Meetings were held for all staff across the Willows Health Ltd practices however it was not clear how information from these meetings were disseminated to staff that could not attend. We were told that staff could listen back to recordings, however due to staff shortages we were told they did not have time to do this.

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 providers other practices made up the primary care network and offered additional appointments via extended access and cervical smear appointments at their other locations.

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

The provider was invested in quality improvement and strived to improve patient care within the locality. We saw some audits had been completed however it did not always show direct improvement for patients at the practice. Whilst some audits were only in the first cycle, and had not yet been reaudited to show improvement, some second cycle audits parameters had changed and therefore it was difficult to see if improvements had happened.
Learning from incidents and complaints was not always captured and clearly disseminated to practice staff to drive improvement.