During an assessment under our new approach
Date of Assessment: 28 July to 30 July 2025. Elm Hayes Surgery is a GP practice and delivers service to 8,992 patients under a contract held with NHS England. The National General Practice Profiles states that demographics are in line with local and national averages. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 10th decile (10 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.
We carried out an announced, focused assessment to follow up on previous enforcement and covering quality statements under Safe, Effective, and Well-led key questions.
At this assessment, the service demonstrated a good learning culture where people could raise concerns, and managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. There were enough staff with the right skills, qualifications and experience. Managers ensured staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. Where patients lacked capacity, staff supported decisions in their best interest.
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. 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. There was a culture of continuous improvement with staff given time and resources to try new ideas.
However, there was a lack of regular documented clinical supervision taking place and no policy to adhere to, which meant that the service was unable to show that they routinely evaluated the competence, scope of practice, and capability of their staff. There was also a lack of evidence of cleaning logs and deep cleaning schedules, and no risk assessments were available for the presence of carpet in consultation rooms where clinical procedures were taking place. This meant there was an increased risk of infection transmission and lack of accountability or evidence of adherence to cleaning standards.
Since the last inspection, the practice had made improvements and is no longer in breach of the legal regulation relating to safe care and treatment. However, the service remained in breach of the legal regulation relating to governance. We have asked the provider for an action plan in response to concerns found at this inspection.