John G. Plummer & Associates Thorpe St. Andrew

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 found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider had made the required improvements.

During our inspection of this key question, we found the registered person had ineffective systems or processes to enable them to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. In particular, relating to the management of fire and electrical safety. Additionally, we found that there were ineffective systems in place to ensure that the registered person had maintained records as are necessary to be kept in relation to persons employed in the carrying on of regulated activities.

This resulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in the detailed findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

We saw that processes in place were not wholly effective for identifying and managing all risks, issues and performance, in particular regarding the management of fire and electrical safety and the recruitment of staff. Improvements were needed to the oversight of the practice to ensure that it was consistently well-led for patients and staff.

The practice must take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.

The practice must take action to complete an Electrical Installation Condition Report (EICR) to ensure the electrical system and wiring in the building is safe.

The practice must take action to ensure that complete recruitment records are completed for every staff member.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records.

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had some systems for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. Improvements could be made to ensure complaints were acknowledged within an acceptable timescale. Following this feedback, the practice told us that improvements were made immediately.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

The practice gathered feedback from patients and responded accordingly.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.