Favell Plus 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 assessed all the quality statements from this key question. 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. Leaders were honest in sharing their experiences and areas they felt needed improvement. They responded proactively to feedback received throughout the assessment process. We found that while there were governance policies and procedures in place, there were gaps in some systems and effective managerial oversight, to ensure they were operating effectively, was lacking. This key question has been rated as requires improvement.

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 practice did not have a formal set of values or mission statement. Instead, there was a practice charter which established the practice’s commitment to its patients. Staff we spoke with were able to describe a shared vision, approach and culture, which placed patient’s needs centrally. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders informed us they regularly communicated with outside bodies like the wider primary care network (PCN) and Integrated Care Board (ICB) to ensure that the practice operated effectively.

The practice had some inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. However, we found multiple gaps in knowledge and understanding for some leaders.

Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area. Staff we spoke with were aware of those with lead roles in the practice.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. However, during our assessment the leadership team advised they did not have a designated freedom to speak up guardian appointed. Staff we spoke with confirmed this. The practice was prompt to respond to feedback and appoint a freedom to speak up guardian. They submitted evidence of an up-to-date protocol documenting this.

The practice valued diversity in their workforce. They worked 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. There were robust, fair and transparent recruitment policies and procedures.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Whilst we found some evidence of good practice, there were multiple areas where management oversight was lacking and systems were not working effectively. For example, there was no clear oversight of staff training and leaders were unable to evidence staff had completed required training. Similarly, there was no oversight of clinical staff registrations with national clinical bodies, such as the Nursing and Midwifery Council (NMC). The NMC is the independent regulator for nurses, midwives and nursing associates in the UK, who maintain a register of qualified professionals. Some of these staff had not received an appraisal for 2 years. Protocols for managing blank prescription security were adopted during our assessment and were not being implemented fully. Clinical read coding was not being used appropriately to record DNACPR and ReSPECT forms within patient records and there was no evidence to demonstrate routine reviews of patient records with these in place. Clinical read coding was not consistently applied to new patient records that had been summarised, making it impossible to assess how many records still needed summarising. Many policies and protocols examined during the assessment had last been reviewed by the management team in the days leading up to and during our assessment, highlighting a lack of regular review systems.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network (PCN) to offer extended access. There was an active and well-established Patient Participation Group (PPG).

There was evidence the practice had systems to support learning, innovation and improvement across the organisation and local system. For example, the practice had established systems to support staff working across the PCN with regular meetings to support learning, development and effective working. Leaders also discussed plans to incorporate artificial intelligence systems to support patient access in the future.