Woodhall Spa New 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

At our last inspection, we rated this key question as good. At this assessment, the rating has changed to requires improvement. We found the service to be in breach of Regulation 17- Good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems and processes did not always ensure that people were safe. Patient care and treatment was appropriate and this was a clear focus for leaders, evidenced through the results of clinical searches of the practice’s patient clinical record system. However, we saw evidence that some systems and processes did not support good governance. There was a lack of understanding of significant events and complaints processes. We saw evidence of a lack of oversight of risk assessments, particularly in relation to fire assessment and infection prevent control. Staff felt leaders were transparent and honest and this created an overall positive environment.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with felt the practice’s aim was to provide good quality patient care and staff felt supported by leaders to do so. Leaders clearly had a people-centre approach which started at the point of triage and followed through the person’s journey at the service. Leaders took pride in ensuring people received appropriate information and treatment in line with providing good quality care. The service created a positive environment for staff to work in. Staff felt able to share their views and felt listened to and valued by leaders. Leaders valued their staff and the contribution they made.

Staff told us there was compassionate, inclusive and effective leadership at all levels. They stated there was a positive environment in which to work and they felt they could share concerns with the management team. Leaders prioritised the quality of the service they delivered with appropriate support for all staff. Some appraisals were out of date but had been scheduled. Staff told us that they recognised leaders had an open door policy and leaders were responsive to their concerns. The practice had implemented regular meetings covering all staff groups and an agenda was produced. Full practice meetings took place alongside additional training for staff. Leaders did not have full knowledge of significant events and what one constituted.

The service fostered a positive culture where people and staff felt they could speak up and their voice would be heard. There was an established route for Freedom to Speak up. Staff felt able to raise concerns directly with leaders and we saw evidence that this was acted upon however not always appropriatelydocumented. We saw an example of a significant event in relation to this that was not formally documented.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Some practice policies were not appropriate, specifically in relation to complaints and significant events. We saw examples where events were not correctly reported and therefore no learning or improvement was made. Leaders carried out risk assessments but they were not always comprehensive and we saw evidence where action was not taken as a result. For example, the fire risk assessment was completed but not all actions had been followed up in an appropriate time scale. An infection control audit was completed but lacked relevant detail and oversight. There was no recruitment policy at our on-site assessment but has since been implemented.

Leaders were open and transparent. Staff collectively embodied this culture and used this when working with external stakeholders. Leaders were regularly engaged with the primary care network and often worked with other practices in the area to enhance the care they provided. We saw evidence that leaders were involved with safeguarding, end of life and care home meetings, which enhanced their understanding of people they served. The management and leadership team met regularly and engaged with all staff at practice meetings. Patients were appropriately referred and the practice followed up on any clinical action needed.

We saw examples of how staff had been given opportunity to develop their skill set and how they were supported in doing so by leaders. Leaders demonstrated that clinically, they sought ways to improve methods and practices however we did not see this across all aspects of the practice. Leaders did not evidence that they had robust management of infection prevention control or fire assessment at the practice. Leaders did not have a clear process for managing complaints and some significant events were missed. Staff were given time to complete required learning and training. The management team developed a continuity plan and had a good knowledge of future challenges they faced. They involved all staff with this. Informal supervision was present at the practice but this was not formally documented or reviewed. The practice carried out various clinical audits which were effective and re-audited to see evidence of implemented change. Relevant topics were chosen that enhanced practice and output at the practice.