Elm Hayes 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 Good. However, the service remained in breach of legal regulation in relation to governance.

This service scored 71 (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 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.

Staff had contributed to the development of the service vision and strategy, which was kept under review. All staff we spoke with were proud to work for the service and had a vision to deliver high-quality patient care. CQC received 14 staff feedback surveys during the inspection, with all confirming the service had a clear vision for the future. Staff told us there was a positive, supportive and friendly culture within the service and they felt supported by GPs and senior leaders.

The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges. They recognised the importance of collaborative working to enhance care for their local community due to their rurality. Staff told us a key aspect of the service’s vision was to have more of a presence in the community, and they were doing this through ongoing initiatives and the use of their patient participation group (PPG).

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders were visible, approachable, professional and committed. Staff felt leaders listened to and supported them, responded to any concerns raised, and modelled the values of the service.

We saw the leadership team worked with other services in the local primary care network and were engaged in the development of primary care services within the surrounding area. For example, the service regularly communicated with other local services to share places on any in-person training courses to maximise training opportunities for staff.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had established Freedom to Speak up arrangements through their GP Federation, BANES Enhanced Medical Services (BEMS), and this information was available to staff via the service’s intranet homepage. Staff were aware of how to raise concerns, but according to the staff we spoke with, they have not needed to use this service because they have not yet had to raise or escalate any concerns.

Staff told us there was an ‘open door’ policy and leaders welcomed feedback for service improvements. There were also opportunities for staff to share feedback about the service through its annual staff survey, which the service acted upon. For example, the 2024 staff survey showed some staff were finding it difficult to balance the conflicting demands of their roles and felt there was not enough staff for them to do their jobs effectively. In response, the service recruited more reception staff and allowed both the administrative and clinical teams protected time for necessary admin tasks. The service had a zero-tolerance policy in relation to the abuse of staff with systems in place to protect people and minimise the likelihood of reoccurrence.

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.

Policies and procedures to promote diversity and equality were in place, and available on the practice’s website. Staff had undertaken mandatory training modules in equality and diversity.

Adjustments had been made to ensure all staff were valued. For example, reasonable adjustments were in place for staff to work flexibly around other commitments, such as childcare or other caring responsibilities.

Management told us they held social events to promote wellbeing amongst staff, for example, team-building afternoons. They also had staff wellbeing activities organised by various teams on rotation, such as baking competitions. Staff felt these contributed to fostering stronger relationships within the teams.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Whilst managers met with staff regularly to complete appraisals and performance reviews, there was no evidence or oversight of regular documented clinical supervision sessions being carried out to ensure staff were consistently supported in their roles. There was also no clinical supervision policy in place for staff to follow to facilitate effective clinical supervision and promote high standards. This lack of oversight meant that the service was not able to demonstrate that they are regularly assessing the capability, scope of practice and competency of their staff through documented clinical supervision.

The service carried out routine infection prevention and control (IPC) audits, including an assessment of the premises. However, these did not identify the presence of carpet, especially in consultation rooms, and fabric chairs throughout the premises, as infection control risks. The use of these increases the risk of infection transmission and contamination and the difficulty in accurate cleaning, especially in the event of body fluids and spillage. There was a lack of oversight of the maintenance of carpets and upholstery since the service were unable to demonstrate regular deep cleaning was being performed or a clearly defined cleaning programme was in place. They could not be fully assured that carpeted consultation rooms were only being used for consultations, and not clinical procedures, and there was no risk assessment, or policy, to reflect this. There was no reference to any deep cleaning schedule in the IPC policy, and it did not include how often the soft furnishings are cleaned, or what actions to take if they are contaminated with body fluids or spillages, which demonstrates a lack of appropriate risk management. However, we highlighted the lack of deep cleaning records to the service, who evidenced that they had since booked for a deep clean to be done 2-weeks after our onsite visit.

There was a lack of oversight and documented evidence of completed cleaning logs within the service. They were unable to demonstrate when and how frequently the external cleaning company were undertaking the cleaning tasks, which can lead to an increase infection risk. The absence of cleaning logs prevented routine audits of these logs to check for completeness and accuracy, which demonstrated a lack of accountability from the service in relation to governance.

However, leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff could access all required policies and procedures and took confidentiality and information security seriously.

Managers held regular 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 through the service’s intranet system.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service worked with their local GP Federation service to offer enhanced access during week-day evenings and Saturdays. This service allowed people to have flexibility in accessing care. They also worked closely their primary care network (PCN) to offer flu and other vaccination programmes. They had weekly PCN Practice Manager meetings, to facilitate communication, share practices, and address shared challenges and priorities.

The service was aware of the needs of the local community and used this to improve outcomes for people by tailoring services to the local needs. The service had recently attended a community and village-led event to showcase themselves and the services they provide and immerse themselves directly into the community. They shared awareness of their ongoing projects and initiatives to demonstrate their efforts in enhancing care services within the local community. Staff spoke positively about the work happening in the local community and were proud to have made an impact.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service had a quality improvement plan in place to help drive improvements in services. Part of the improvement plan focused on triage, and the implementation of the service’s new clinical triage system. Staff told us this triage system was a productive change and had positively transformed the duty sessions by enabling the service to prioritise people effectively, and signpost others to more appropriate services, which helped to reduce GP workload and pressure. The feedback we got from people who used the service was mixed, but overall, they felt the new system was working well.

The service demonstrated other examples of quality improvement activity, particularly through a new autism spectrum disorder (ASD) friendly project, which focused on improving services for people with learning disabilities and autism. Through this project, the service had created sensory boxes containing equipment which could be used for distraction and communication tools. They had named ASD champions, and all staff received online mandatory training in learning disability and autism awareness, with clinical staff also having in person training. They offered a quiet waiting area for people and could book appointments at quieter times to ensure the environment was accessible and welcoming to people with autism.

All staff were encouraged to put forward and test out new ways of working, and we saw examples of this during our inspection. For example, there had been ongoing work to improve uptake of annual reviews for patients with learning disabilities, with the practice achieving full compliance. Staff and leaders were determined and driven to make improvements to enhance services for people.