The Lakeside 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; supported learning and innovation; and promoted an open, fair culture. At our last inspection, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

Leadership, management and governance arrangements failed to provide effective oversight of the service. Leaders did not have effective systems to identify, assess and manage risks, monitor quality or drive improvement. Although staff understood their roles and responsibilities, systems and processes were not sufficiently robust or well embedded to ensure care was delivered safely and effectively. Internal policies and procedures were not followed, and leaders did not provide adequate oversight to identify and address risks in a timely way or drive the improvements needed. Poor governance and oversight, contributed to the ineffective management of day-to-day risks and reduced the provider's ability to ensure safe and consistent care.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff consistently described a positive and supportive working environment. They told us they felt valued by colleagues and leaders and spoke positively about the relationships within the practice. Staff described an open-door approach, stating they were able to seek advice from GP partners and colleagues when needed. Feedback from members of the wider multidisciplinary team was also positive, with external professionals describing the practice as approachable, supportive and responsive.

However, the positive culture described by staff was not consistently reflected in the provider's governance arrangements. We found examples where concerns raised by staff, including matters relating to patient safety and safeguarding, had not been formally investigated, appropriately documented or used as opportunities for organisational learning. This limited assurance that staff could consistently raise concerns knowing they would be managed transparently and lead to meaningful improvement.

Leaders were visible within the practice and staff consistently described them as approachable and supportive. Staff told us they could seek advice when required and described positive working relationships with GP partners and colleagues. Members of the wider multidisciplinary team also spoke positively about the support they received from practice leaders and described collaborative working arrangements.However, there was a lack of oversight and leadership to ensure concerns were acted on appropriately which reduced assurance that leaders consistently promoted a culture of openness, accountability and learning.Leaders recognised some of the challenges facing the practice, including workforce pressures and increasing demand. However, they had not implemented effective arrangements to ensure staff were consistently supported through appropriate training, structured supervision, workforce planning and clear communication. Whilst staff felt personally supported, the systems required to enable them to carry out their roles safely and effectively had not been fully developed.Although leaders demonstrated commitment to patients and staff and had established positive working relationships within, they had not consistently translated this into effective leadership arrangements that ensured concerns were addressed appropriately.

Staff told us they felt able to raise concerns with leaders and described an open-door approach within the practice. They said they were comfortable discussing issues affecting patient care and their working environment and did not express concerns about victimisation or barriers to speaking up. There was a Freedom to Speak Up Guardian, and staff knew who this was and how concerns could be raised. However, the provider could not demonstrate that concerns raised by staff were consistently managed through effective governance arrangements. Concerns were not consistently recorded as incidents or escalated to significant events in accordance with the provider's own policies and procedures, reducing assurance that issues raised by staff were appropriately investigated, acted on and used to improve the quality and safety of the service.

Staff told us they were treated fairly and with respect and did not raise concerns about discrimination, bullying or exclusion within the workplace. We found no evidence that staff were treated unfairly because of protected characteristics, and leaders described an inclusive approach to supporting staff.

The workforce was predominantly white British, reflecting the local area, with some diversity amongst locum clinicians. Although we saw limited evidence of formal initiatives to promote equality, diversity and inclusion within the workforce, we found no evidence that leaders failed to promote an inclusive working environment or that staff were disadvantaged.

Leaders had failed to establish effective governance, management and oversight systems to ensure the delivery of safe, high-quality and sustainable care. Whilst policies and procedures were in place, they were not consistently implemented, monitored or followed. As a result, leaders were unable to provide assurance that risks were systematically identified, assessed, mitigated and reviewed, or that services were delivered in accordance with legislation, national guidance and the provider's own policies.

Governance arrangements were ineffective and failed to provide oversight of significant events, incidents, complaints, safeguarding, recruitment, mandatory training, medicines management, infection prevention and control, health and safety, fire safety and environmental risks. We found repeated examples where concerns had been identified but were not appropriately investigated, documented, risk assessed, escalated or followed through to completion. Opportunities to identify learning, share outcomes and reduce the risk of recurrence were consistently missed, and leaders could not demonstrate that governance systems were effective in identifying or responding to risks across the service.

Systems for monitoring performance and driving quality improvement were ineffective. Leaders were unable to demonstrate that patient feedback, complaints, clinical audit, National GP Patient Survey results, Friends and Family Test feedback or other sources of information were routinely analysed to identify themes, inform decision-making or drive sustained improvements. Where actions had been identified, there was limited evidence that these were monitored, reviewed or evaluated to ensure improvements had been embedded and remained effective.

Leaders worked collaboratively with partner organisations to support the delivery of coordinated care. Feedback from care homes and members of the PCN multidisciplinary team was consistently positive, with partners describing GPs as approachable, responsive and supportive. Staff described effective communication with community services and appropriate use of multidisciplinary working to meet patients' needs.The practice had established effective working relationships with external partners to support continuity of care and access to additional services and social prescribing where appropriate. These partnerships supported the delivery of person-centred care and enabled patients to access services beyond those provided directly by the practice.However, there was limited evidence that leaders routinely used feedback from partner organisations to evaluate the effectiveness of these arrangements or to identify opportunities for service development and improvement.

Leaders had not established an effective culture of learning, improvement and innovation. Although the practice undertook some audits and collected information from a range of sources, governance systems did not ensure that this information was routinely analysed, used to identify themes or translated into meaningful and sustained improvements.

Opportunities to learn from significant events, incidents, complaints, safeguarding concerns and patient feedback were repeatedly missed. We found limited evidence that learning was consistently shared with staff or that actions arising from concerns were monitored to ensure they had been implemented and remained effective. As a result, leaders could not demonstrate that the practice had embedded a culture of continuous learning or improvement.

Quality improvement activity lacked strategic oversight. Leaders were unable to demonstrate that clinical audit, National GP Patient Survey results, Friends and Family Test feedback and other sources of assurance were routinely used to evaluate performance, drive service improvement or improve patient outcomes. Where areas requiring improvement had been identified, there was insufficient evidence that actions were evaluated to determine whether they had achieved the intended outcomes.

Although staff demonstrated a willingness to improve the service, governance arrangements did not support continuous learning or innovation. The absence of effective systems to identify, monitor and evaluate improvement meant leaders could not provide assurance that the quality of the service was improving over time.