The Mockett's Wood Surgery Also known as The Partners T/A Mocketts Wood 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

Some systems and processes required refining and strengthening. There were inconsistencies in triage processes and an absence of consistent clinical governance systems in place to ensure safe practice was maintained. Staff were encouraged to seek clinical advice and guidance, but the partners did not have protected time to support staff or undertake governance activities.

Leaders and staff shared a vision to provide good accessible and responsive care. Their culture was founded on listening, learning and trust. Leaders were visible, knowledgeable and supportive to staff and people. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.

We found breaches of regulation in relation to regulation 12 safe care and treatment and regulation 17 good governance. We have asked the provider to take action in response to the concerns found as this assessment.

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.

Staff told us they cared about their work and were committed to getting it right. They respected the partners and told us they were accessible to speak to and obtain guidance from. Staff told us most discussions were held informally and as situations arose to ensure timely actions. Staff told us they felt able and supported to raise questions or concerns with the management team.

There were established and effective systems in place to promote adherence to the values of the organisation. There were appraisal processes in place for clinical and non-clinical staff. Individual and collective performance was consistently monitored by the leadership team.

Systems and processes were not always defined and adhered to by managers. Whilst leaders for key responsibilities were identified, the scope of their roles and responsibilities were not clearly defined and documented and they were not held formally accountable. This led to disparities in the timeliness and quality of care provided to people. The provider acknowledged they needed to improve their documenting of inclusive governance systems.

The provider and management team demonstrated that they had the potential to ensure organisational vision could be delivered, and risks were identified and managed appropriately.

Staff told us their management team and colleagues acted with openness, honesty and transparency in the dealings with one another and people. Staff told us they were trusted to work with autonomy but had the support of the management team.

The practice had nominated speak up champions for staff to approach if they felt unable to directly raise concerns with the management team. Staff also had access to external speak up champions if they felt more comfortable to do so. Concerns raised by staff informally and formally were all recorded, investigated and responded to and any learning identified and shared to drive improvements.

Staff told us they valued their colleagues and the opportunities to support one another, share learning and diversify their knowledge and skills base. Staff felt confident raising concerns or questions and welcomed the support of the Integrated Care Board (these areNHS organisations responsible for planning health services for their local population).

There were established, effective and inclusive systems and processes in place to demonstrate the leaders had reviewed, considered and improved the culture of the practice. Staff views and opinions were sought directly by the management team. Reasonable adjustments had been made in response to health and safety considerations. For example, ensuring staff had access to appropriate ergonomic chairs and use of headsets.

Some staff were not effectively held accountable for their responsibilities. Where duties had been delegated the lead clinician had not assessed the skills and competency of the person to undertake the role and check risks were identified and managed appropriately. For example, the medicine management lead did not effectively oversee and ensure the timely and appropriate actioning of Medicine and Healthcare product Regulatory Agency alerts.

The provider had not established effective governance systems to effectively reduce and improve the prescribing behaviours of staff. The practice remained a high prescriber for antibiotics. Overprescribing of antibiotics in primary care is one of the important drivers ofantimicrobial resistance. The provider had not conducted checks on individuals to ensure adherence to safe practice.

Operational practices were not accurately reflected in the provider’s policies. For example, we found different forms were being used than those stated and designed to support staff and promote effective and defensible decision making. We found documents recently reviewed and approved by the provider included references to discontinued organisations and failed to provide essential details for staff to undertake activities effectively and safely.

We found there was no established and effective system in place to ensure consistent and accurate coding of clinical information.

Staff and leaders operated with openness and transparency. They collaborated with all relevant external stakeholders and agencies. Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. Staff and leaders engaged with people, communities and partners to share learning with each other that results in continuous improvements to the service.

The Patient Participation Group were valued as critical friends and their experiences and contribution listened to and considered when proposing changes to the service.

The provider and management team reflected on learning from previous adverse incidents, understood the risks, strengthened operating systems or improved people’s skills and knowledge to mitigate or remove the risks from re-occurring. For example, they had commissioned additional training for their staff to increase their confidence and skills in responding to emergency incidents.