Henmore Health – Ashbourne 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 Good. At this assessment, the rating has changed to requires improvement.

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and engagement. The provider told us they had a clear vision which they regularly reinforced through internal communications and leadership engagement. We saw that it was included in staff appraisal forms. However, this had not been effective because feedback received from staff working at the practice showed 7 staff were not aware of the practice’s vision and 7 stated they were however, there was a lack of consistency in what staff thought it was. Sixteen members of staff told us they had not been involved in developing the vision.

There was a mixed response from staff regarding the culture within the practice. Some staff were positive about the culture and described it as open, supportive, demanding and professional. Other staff felt there was a closed culture and feared retribution if they spoke out. Some staff did not feel listened to and some staff felt there was a blame and bullying culture. Some staff felt their concerns were not acted on, for example concerns over staffing levels. Where staff felt their concerns were listened to they told us they were not always acted on in a timely manner. For example, putting updates onto the practice’s social media page.

The provider was aware of the projected increase in the local population and were working to address future challenges such as expanding the building.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Feedback from staff was extremely mixed. Most staff told us leaders in the practice was approachable however, some staff stated leaders did not always respond to concerns raised.Some staff told us they felt listened to, that leaders were visible and supportive to the needs of staff. They told us leaders strived to make improvements within the practice. Other staff told us they were neither visible nor compassionate to the needs of staff. The Patient Participation Group (PPG) told us they felt that hands on operational management was lacking.

Some staff expressed concerns about communication within the practice and the failure to clearly explain to staff why changes were implemented so swiftly without consultation with staff or patients to understand potential risks and impact. For example, the move over to complete total triage, the movement of clinical staff from downstairs to upstairs and the shortening of hours at the dispensary practice. A representative for the PPG told us there was a need to review roles and responsibilities within the practice as it was unclear who was managing what. They thought that staff were becoming unsettled. Some staff felt that some of the leaders made quick decisions without proper consideration of the negative impact of their behaviour on staff which affected transparency and contributed to a reactive environment.

The service tried to foster a culture where people felt they could speak up and their voice would be heard. They had established Freedom to Speak up arrangements outside of the practice to support staff. Staff were aware of how to raise concerns and told us they had attended a presentation on this at a training session.

However, some staff told us they feared retribution if they spoke out and they did not feel listened to. Some staff told us there was a bullying culture within the practice.

The service valued diversity in their workforce. They told us they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Two members of staff told us of the adjustments and support that had been put in place to support them through challenging times. Policies and procedures to promote diversity and equality were in place. Staff had completed training in equality and diversity.

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. Some staff told us they were not always sure who to go to with a concern and were often sent from one person to another to get their concern addressed. Not all staff were aware of who the leads were for safeguarding or infection prevention control. There had been a breakdown in the relationship between leaders and some clinical staff regarding the governance arrangements and potential safety risks during the introduction of the new triage system. This had resulted in some clinical staff leaving the practice.

Staff could access policies and procedures and there was a system of reviewing them. However, some policies still referenced Clinical Commissioning Groups which were replaced in July 2022 by Integrated Care Boards. Following our assessment the provider updated their policies.

The provider’s CQC registration was incorrect at the time of our assessment. There is a legal requirement to ensure this is correct. Following our assessment the provider submitted applications to add the missing partner.

The provider had failed to correctly display their CQC rating, as required by law, within the practice and on their website. Following our assessment, they sent us photographic evidence that this was now in place.

A system of regular audit of the prescribing and consultations of non-medical prescribers was not in place and clinical supervision was inconsistent.

However, managers met with staff regularly to complete appraisals and performance reviews. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and shared these with staff. Staff took patient confidentiality and information security seriously.

The service mostly understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Feedback from the 3 care homes where the practice provided care and treatment and the practice’s Patient Participation Group was mostly positive. The service collaborated and had made adjustments to improve coordination of their service with community healthcare services, including the community support team and Health Visitors.

However, a representative from a care home expressed concerns that they had heard the home visiting team was changing but no one from the practice had been in touch to discuss this and explain why.

The relationship between practices within the Primary Care Network (PCN) had broken down however, there were systems under review to ensure patients continued to receive the services previously provided by the PCN.

The service mostly focused on continuous learning 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 used complaints and significant events to drive improvements.

The service had conducted patient surveys and analysed the results. Changes made as a result of the surveys included the introduction of a medicines home delivery service and a new telephone system had been installed to improve telephone access. An online patient triage system had been put in place and they surveyed patient feedback on a monthly basis. However, a representative for the PPG told us it was unclear how this information was being used to improve the service as it was a basic scoring system rather than qualitative data.

Some system wide audits had been completed, for example infection control however, clinical audits to drive improvements in patient outcomes had not been completed. The provider told us this would be re-established when the new salaried GPs were in post.