Castlegate & Derwent 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 assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to inadequate.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Theydid not understand the challenges and the needs of people and their communities. Leaders had not done a review of a newly implemented patient triage system despite staff raising legitimate concerns about it. They failed to act when staff raised concerns around patient safety. Conflict between senior clinical leaders had led to a toxic culture where staff felt frightened to speak. Staff reported feeling bullied and manipulated into working in situations they did not feel comfortable in doing so.

The practice did not have a sustainable plan to repair these issues at the time of our site visit, despite these issues being raised at previous assessments. The negative culture had been noted by staff, leaders, PPG members and an MP.

The service did not have inclusive leaders at senior clinical level who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. Ongoing conflict between clinical leaders had impacted clinical care. Staff told us they did not know which leaders processes or instructions to follow.

Staff told us non-clinical management were approachable and responded to any concerns raised. However, staff told us clinical leaders would not respond to concerns if they raised them with them.

There was no effective succession planning at the time of our assessment, we asked leaders to explain intentions for the next twelve months, we were not provided any evidence of a plan the conflict between clinical partners had impacted the whole practice. One partner had spoken of potentially merging with other practices in the local area this was in infancy stages. The practice was actively trying to recruit GPs.

People did not feel they could speak up and that their voice would be heard. We saw examples of staff raising concerns surrounding patient safety. These were ignored by clinical leaders. Within the partnership, there was fear amongst leaders.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, however felt frightened to do so. Staff felt bullied. A report had been written by an external Freedom to Speak Up Guardian. They had spoken to numerous members of staff. It was not clear how leaders intended on addressing the serious issues highlighted in the report.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them. There were disparities in the experience of all staff. Staff told us they did not feel included or valued. There were inconsistencies in how leaders approached preventing bullying and harassment. Staff reported negative interactions with some clinical leaders.

Policies and procedures to promote diversity and equality were in place. Workplace adjustments had been made to ensure all staff were able to carry out roles appropriately. Staff were up to date with equality and diversity training.

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. Clinical leaders had not reviewed patient triage despite being told by members of staff it was not working. The implementation of a ‘quick’ clinic had not been supported by staff and leaders. One clinician commenced these despite concerns, this demonstrated a lack of collaboration between leaders.

Management supported staff, but staff did not feel supported by clinical leaders. Staff we spoke with were not clear on their individual roles and responsibilities. They told us conflict within the GP partnership caused issues. Managers met with staff regularly to complete appraisals and performance reviews. The provider had not established governance processes that were appropriate for their service. Leaders told us of varying examples of how processes worked within the practice.

Leaders were unable to produce a process to clear diary dates, they told us not all were legitimate and some patients had been reviewed in secondary care, nothing was in place to reduce this.

Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Staff did not always maintain patient confidentiality, and we were not assured information security was taken seriously by leaders.

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. PCN working was minimal due to staffing issues.

Leaders did not always promote collaborative working with external stakeholders and other services. Leaders were not transparent with stakeholders around issues within the practice.

Staff and leaders did not always collaborate or communicate openly with all relevant external stakeholders and agencies. We noted incidents of harm, and some safeguarding concerns that had not been appropriately reported.

There was limited evidence of the service working with other organisations. This impacts people’s experience of moving through their care pathway and may impact flow in the wider system.

Leaders had not invested enough in developing networks with people, communities, and partners. There was a lack of evidence of learning and sharing with others or finding new ways to improve care.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

They did not actively contribute to safe, effective practice and research. The practice had reduced numbers of trainee doctors. Leaders told us due to staff leaving, audits and quality improvement activity were not happening. At the time of our assessment there was no research that the whole practice was participating in. One clinician had commenced some research surrounding respiratory conditions, this was in infancy stages and due to this member of staff leaving it was unclear if this would be carried on. Since our inspection the practice have told us there is ongoing research around virology and some local research aroundasthma and atrial fibrillation. We will review this at our next inspection.

We noted inconsistencies in prescribing audits. Leaders were not able to provide consistent answers in relation to ongoing work. We did not see evidence that leaders participated in reviews of patient deaths to highlight any themes and trends, or to improve palliative care.