Kirkgate Surgery

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• 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 leadership, management and governance assured high-quality, person-centred care; supported learning and improvement; and promoted an open and positive culture. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

Governance systems were not always effective in identifying, monitoring and responding to risks. We found gaps in oversight relating to health and safety, infection prevention and control, workforce records and compliance monitoring. Leaders could not always demonstrate effective systems to maintain accurate records, monitor actions and ensure risks were managed appropriately.

The practice was in breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

The practice had a clear set of vision and values which were displayed throughout and understood by staff. Staff described a shared commitment to providing high-quality, patient-centred care and understood their role in supporting the practice's aims and objectives. Leaders and staff recognised the needs of the local population and discussed how services were adapted to meet those needs.

Staff spoke positively about the culture within the practice and described leaders as approachable and supportive. They told us they felt listened to and able to raise concerns or suggest improvements. Staff and leaders promoted equality, diversity and inclusion and demonstrated a compassionate and respectful approach towards both colleagues and patients.

Leaders reviewed feedback from patients and staff and used this information to support service development. Staff told us they felt supported in their roles and valued as members of the wider practice team. The culture within the practice encouraged openness, learning and a focus on delivering care that met the needs of its population.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The practice did not always have effective systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

The practice had some governance arrangements in place, including an operational action tracker, a programme of practice meetings and systems to support information governance. An external provider supported the management of information governance requests and compliance with data protection requirements. Staff understood their roles and responsibilities and told us leaders were approachable and supportive. A Patient Participation Group (PPG) was established, with information and meeting minutes available within the practice. The practice also had an up-to-date business continuity plan to support continuity of care in the event of significant disruption.

However, governance systems were not effective in providing leaders with oversight of risks and compliance. During the assessment, leaders were unable to readily access or provide several documents relating to health and safety, infection prevention and control and workforce governance. A number of records were submitted only after the onsite visit, and leaders acknowledged there were gaps in historical records and organisational documentation. Systems had not ensured that risk assessments remained up to date, actions identified through assessments and audits were completed, or that appropriate records were maintained to demonstrate ongoing monitoring. We identified gaps in staff records, limited assurance of staff immunisation status in line with current guidance, and the absence of an effective process for recording annual professional registration checks. There was also no staff training matrix to enable leaders to maintain oversight of training compliance. These findings demonstrated that governance systems were not always effective in identifying, assessing and responding to risks or maintaining complete and accurate records.

Leaders from the practice were open and reflective regarding areas where further development was required. Discussions identified opportunities to strengthen governance, health and safety, and compliance oversight. Leaders demonstrated a commitment to improvement.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.