Fernclough Surgery

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• 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating is requires improvement.

The service was in breach of legal regulation in relation governance.

This service scored 62 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years and worked with partner agencies to address these challenges. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, and systems of accountability but governance systems were not in place to ensure a well-led service.

The provider did not have effective governance systems in place to ensure safe, compliant, and a well-managed service. There was a lack of risk management, with no key risk assessments in place, including those related to health and safety, fire safety, legionella, and reasonable adjustments. Oversight of staff compliance was lacking with several staff having dated Disclosure and Barring Service (DBS) checks and there was no risk assessment in place to mitigate associated risks or determine whether renewals were required. Training governance was not always in place, as mandatory training such as basic life support and safeguarding was out of date for multiple staff members, including locum staff. There were gaps in incident reporting, as an incident that had been reported to the police had not been notified to CQC as required. We found that prescriptions were being stored in printers overnight and the serial numbers were not logged when blank prescriptions were received. This was not in line with NHS guidelines.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.