Nettlebed 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

Leadership and governance were not sufficient to assure systems were operated effectively and risks were not always identified and mitigated. There was a supportive culture among the staff group. However, the practice operated without effective oversight of its performance to ensure quality was maintained and improved where necessary.

This key question has been rated as requires improvement.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice was led by a single-handed GP, supported by an experienced GP, a practice manager and business administrator / strategic lead. There was also a patient services team lead. There was a collaborative approach to leadership within the practice and an open culture.

There was a lack of effective planning for the sustainability of services provided. Several clinical staff members had left the practice in months prior to the inspection. There had been minimal strategic planning or response in how to mitigate the shortfall of staffing and the impact on the remaining staff group. Staff reported a pressured environment where meeting the needs of patients required working outside of process and allocating appointments to administration time. This had an impact on governance processes due to a lack of time to oversee systems and processes.

The practice benefited from an experienced practice manager and support staff. This enabled staff to act independently on providing services.

However, some staff noted that informal feedback could be improved with more formal channels of feedback, to ensure that leadership were alerted to any workplace concerns and then able to make changes where required. Although there was a supportive culture, staff feedback was not always acted on when reported. For example, we saw appraisal feedback stating a staff member did do not have time for their professional development to ensure they were up to date with national guidance but this was not acknowledged in the recording of the appraisal by the appraiser nor was it noted for action.

The was a business administrator and strategy lead involved in the running of the practice. They were involved in key aspects of governance such as human resource.

However, their role was not clearly defined for staff to enable them to understand the responsibilities and accountabilities of this staff member. The staff member did not have the required training or induction needs reviewed in line with their role. This posed a risk to the ability to function within a system of governance.

The practice had established Freedom to Speak up arrangements in the primary care network. Staff were aware of how to raise concerns and were confident to do so if needed.

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

Policies and procedures to promoted diversity and equality were in place. Staff did not always receive training in equality, diversity and inclusion.

The service had delegated responsibilities, roles and systems of accountability. However, the provider did not support staff to lead on their various areas of governance and did not monitor the effectiveness of governance systems. This led to poor monitoring of safety systems, a lack of supervision of staff and risks not being identified and mitigated. For example, systems to mitigate risks related to fire, infection control and medical emergencies were not functioning and we identified risks the provider had not acted on. The dispensary was not effectively managed with insufficient audit in place and operating procedures were not always clear. This led to risks associated with the management of the dispensary which may pose a risk to people who use the service. Whilst some arrangements were in place, these were not consistently effective in identifying, monitoring, and mitigating risks.

The provider did not ensure staff were always suitably trained and provided with adequate supervision and development to fulfil their roles. Although appraisals took place for some staff members, they did not always lead to actions to support staff or as part of quality improvement. The provider had not ensured appropriate levels of staffing and staff cover during absences.

There were meetings held with staff, during which they discussed some operational and clinical areas. However, significant events and complaints were not always reflected on to ensure learning and actions were fulfilled.

The service understood their duty to collaborate and work in partnership, so services could provide care for people with a team approach. Patients care was coordinated with external services as needed. The provider worked with other practices within their primary care network.

Patient participation group (PPG) meetings took place and information sharing was two ways between the PPG and practice.

The service did not have a focus on continuous focused on continuous learning and quality improvement. Insufficient governance systems limited the ability of the service to identify areas for improvement and proactively implement changes.

Some clinical audit did take place and the practice monitored standards of clinical care.