The Densham 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

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. 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 regulations in relation governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Practice management told us that there was a vision and values statement, which they followed. This was displayed within the practice. When surveyed, most staff agreed that the practice had a clear vision for the future. Management told us they were in the process of upgrading their telephony system, however the process was being delayed due to factors external to the provider.

The service had a shared vision, strategy and culture. 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 told us they focused on staff well-being by being supportive towards staff needs. For example, they carried out surveys to understand any areas that staff needed more support with. Staff told us leaders in the practice were approachable and responded to any concerns raised.

The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities. Processes were in place to support staff such as annual leave, flexible working arrangements.

The service fostered a positive culture where people felt they could speak up and their voice would be heard Staff were aware of how and when to contact the freedom to speak up guardian.

The practice had established Freedom to Speak up arrangements with another practice in the primary care network. Deputy managers within the practices were the speak up guardians and provided support to staff from the opposite team. This arrangement ensured that staff could speak openly about any concerns they wanted to raise. There was a whistle blowing policy which staff were aware of.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. There was inclusive recruitment, and this was reflected in the diversity of the staff team. Staff from different faiths were supported to practice their faiths and were given designated spaces so they could do this as appropriate.

Staff told us they have completed equality, diversity, and inclusion training. Records also confirmed this training was completed by staff. Policies and procedures to promote diversity and equality were in place.

Leaders told us they had initiated a lot of change within the last 18 months to improve governance and assurance processes. We found more work was required in these areas. Prior to this there had been a period where there was no permanent practice manager, and this had impacted on the effectiveness of governance processes. The provider had tried to establish governance processes that were appropriate for their service, however we found that a number of these processes were not operating effectively. The provider was also making changes to align governance structures with another practice based on the same site to facilitate joint working. Staff could access policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

We could see that improvements had been made. However, there were still some gaps in the overview of assurance and some processes were not always effective. For example, not all staff had received the statutory training in meeting the needs of people with learning disabilities or autism and the practice governance systems had not identified this as a priority. There were some out of date medicines stored in the medicine’s refrigerator, leading to a risk they could be administered in error. This had not been identified in regular checks on medicines. The practice did not have effective oversight of staff who were due an appraisal. Although we could see there were arrangements in place, and most staff had received an appraisal, there were some gaps that had not been identified through governance processes. The practice had been gaining assurance on the suitability of a new staff member to undertake a role by using Disclosure and Barring Scheme (DBS) checks obtained by previous employers. Whilst this went someway to manage the risks, the practice had not risk assessed whether this was appropriate. For example, by considering was the DBS check requested of the right level; was it for a similar role to the one carried out previously when the DBS was obtained; and how long ago was the check carried out. The assurance processes had also not identified that non-medical staff were coding they had completed medicine review when they had not completed them, and this was not part of their role. The practice took swift action to address all these after we highlighted them.

The practice engaged and sought feedback from patients via surveys, complaints and compliments. They had made efforts to encourage patients to contribute their views via a patient participation group but had not yet been successful in recruiting members.

We found staff and leaders were open and transparent, and they told us they collaborated with all relevant external stakeholders and agencies.

The service understood their duty to collaborate and work in partnership, so services work 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. Staff were able to demonstrate effective working relationships with the PCN, particularly the use of additional staff through the additional roles reimbursement scheme (ARRS) to improve access to care for patients. There were regular meetings with partner organisations, such as local leads for safeguarding to ensure safe and effective service delivery for vulnerable patients. The practice contributed to the vision for the PCN area and was actively involved in discussions about future direction.

There was a learning culture in the practice which staff and leaders actively participated in. There had been a lot of change in the practice to address previous gaps in assurance systems. Also to move towards aligning processes with another practice on site to facilitate joint working. Leaders told us they anticipated further change as they were looking at the feasibility of merging the practices to support sustainability of service provision in the area.

There were systems and processes for learning, continuous improvement and innovation. The practice had an improvement plan in place to help drive improvements in services. We saw some evidence of supervision, appraisal and training including support given to staff to develop in new or extended roles. We saw that through the practice’s own assurance systems improvements to clinical care were identified and processes established to address areas of concern. However, these processes were not always operating effectively as we found gaps in staff training and some staff appraisals.