Barnsley Road 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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care and supported learning and innovation. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement. The service was in breach of legal regulation in relation to safe care and treatment.

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.

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

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 did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Most staff were new to the practice, including the practice manager, and there had been a staff shortage for some months due to staff leaving or retiring. Leaders and managers were approachable and supportive and staff we spoke with understood their individual roles and responsibilities. However, some tasks had not been adequately completed and staff told us there had been insufficient time to complete these. There was a lack of management and provider oversight including oversight of clinical processes and formal clinical supervision was not provided. Governance processes, such as management of health and safety and medicines, had not been maintained over a long period of time and risk assessments, such as the fire risk assessment, had not been reviewed and identified risks actioned. Policies and procedures had not always been fully implemented and followed by staff for example, incident reporting, fire safety checks, recruitment and management of medicines. Information security polices had not always been followed, we found a smart card (a card used to access online patient records) belonging to a staff member who was not in the building left on a desk in an empty office, this was immediately given to the manager. The new manager had recommenced practice meetings with staff, any actions arising from these meetings were recorded. The previous manager had met with staff to complete appraisals and the new manager had a plan to undertake appraisals and performance reviews for new staff. Following the assessment the provider submitted information on the actions taken to improve.

The service did not collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners. CQC had received concerns about difficulties in communication between the practice and other health professionals relating to care of patients due to GP requests for information in writing in all cases before responding. The GP and staff told us urgent calls would be put through to the GP or relayed to the GP via a task on the IT system if the GP was attending to a patient appointment. All communication relating to patients was also requested in writing to minimise the risk of miscommunication and to ensure an audit trail for the patients notes. Meetings with community healthcare services to review and ensure seamless care were not undertaken, for example, for complex patients or those at higher risk of hospital admission and the new practice manager was looking to implement these. A patient participation group (PPG) who would represent the views of people using the service had not been developed.

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.