Updated 7 May 2025
Date of Assessment: 23 June 2025 to 11 July 2025. Haden Vale Medical Practice is a GP practice and delivers service to 8400 under a contract held with NHS England. The National General Practice Profiles states that 80.85% of patients are White, 9.65% Asian, 3.97% Mixed, 2.88% Black and 2.65% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: The service had a learning culture and people could raise concerns, but we found learning was not always shared with the whole team to improve the quality and mitigate future risks. Managers investigated incidents thoroughly. Staff managed the majority of medicines well; but further improvements were needed to ensure clinical alerts were acted on and regular reviews were in place for people on high risk medicines. The facilities and equipment met the needs of people, were clean and well-maintained, however we found infection control processes needed further strengthening. There were enough staff with the right skills, qualifications and experience, but we found some staff had carried out clinical assessments without the appropriate qualifications or supervision.
EFFECTIVE: People were involved in assessments of their needs, but we found systems needed improvements in the management of long term conditions to ensure people received the appropriate reviews, care and treatment. Staff reviewed assessments taking account of people’s communication, personal and health needs. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles, however we identified concerns regarding the management of staff in clinical roles, particularly in relation to the lack of clinical oversight as well as gaps in staff competencies and knowledge. Governance arrangements needed strengthening to mitigate risks. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.
We found breaches of regulation in relation to Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance. Following the onsite assessment, we received evidence to demonstrate the actions the provider had taken in relation to some of the clinical concerns we identified. We have asked the provider for an action plan in response to the other concerns found at this assessment.