Well Street 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 in January 2016, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

The service was in breach of legal regulation in relation to Regulation 17 (Good Governance). The breach reflected a failure of clinical governance oversight. Weaknesses in the documented systems designed to identify, monitor and act on clinical risk, premises risk, recruitment, staff training and infection prevention and control meant that a number of concerns were not identified by the practice prior to inspection. These are set out in detail under the Safe key questions of this report and are captured within the Regulation 17 breach. We have asked the provider for an action plan in response to the concerns found at this assessment. The provider supplied it within the requested timeframe.

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 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 across all levels, both clinical and non-clinical, described and demonstrated a shared commitment to the values of the practice. All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was a teaching practice with sustained investment in staff development, active engagement with the primary care network and local practitioner forums, and a track record of working with the community to understand and respond to the needs of a diverse local population. The provider was aware of the projected increase in the local population and was working with partner agencies to address future challenges. A positive, compassionate and listening culture was consistently described by staff, with an open-door approach to leadership and regular forums for reflection and collective problem-solving through weekly clinical journal clubs, fortnightly whole-staff meetings, and monthly nurse meetings. Embedding understanding of equality, diversity and human rights at all levels, formally identifying and documenting risks to delivery of the strategy, and monitoring progress against the strategy in a structured way were areas for continued development.

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 at all levels described leaders as approachable, visible, and responsive to concerns, and spoke warmly about their management during interviews. Leaders were observed and described as modelling the values of the practice. The leadership team worked with other practices in the primary care network and was engaged in the development of primary care services within the local area. Throughout the inspection, leaders demonstrated openness, self-awareness, and a genuine commitment to addressing identified concerns. They took immediate ownership of the findings discussed at feedback, engaged constructively with the inspection process, and moved quickly to mitigate identified risks during and immediately following the on-site assessment. The partnership also acknowledged, openly and without defensiveness, that arrangements to cover the practice manager's role during periods of planned absence required strengthening, and committed to addressing this as part of the post-inspection response.

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

The practice had established Freedom to Speak Up arrangements through the primary care network, and the staff we spoke with were aware of how to raise concerns. Staff across all levels, both clinical and non-clinical, described feeling comfortable raising concerns and felt their voices were heard by leadership. The open-door culture described consistently across interviews, combined with regular whole-staff forums at which clinical concerns and emerging risks were discussed, supported an environment in which speaking up was both normalised and valued. Staff we spoke with were also able to describe the practice's duty of candour process and understood their responsibilities when things went wrong.

The service valued diversity in its workforce. They worked 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. Staff told us they were treated fairly and felt valued by leaders, and described a working environment in which difference was respected and supported. Adjustments had been made to ensure all staff were supported in their roles. Senior leaders had addressed concerns related to discrimination and took steps to promote an inclusive and equitable working environment. The practice had taken steps to build a workforce that reflected the community it served.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

The governance infrastructure did not meet the required standard at the time of inspection. Leaders had not ensured consistent oversight of clinical safety, medicines management, recruitment, staff training, premises risk, and infection control, with shortfalls in each of these areas identified during the assessment and set out in detail under the Safe key question of this report. Core governance artefacts were not produced during the assessment, policy review arrangements were inconsistent, and there was no single lead partner with overarching accountability for governance. A pattern of reactive compliance was evident throughout, with gaps addressed on or immediately before the day of assessment. Following the inspection, the provider responded promptly and with evident commitment to improvement. A structured governance framework was established, named partner accountability was clarified, and new policies, protocols, registers, and action plans were produced across all identified areas. Triangulation with the Integrated Care Board raised no additional concerns, and the National Professional Advisor GP considered the findings to present a low to moderate risk for a practice of this size. No serious incidents had been reported between inspections, and no historic pattern of harm or enforcement was identified. The provider's openness and willingness to take immediate corrective action have materially mitigated the risks identified.

The service understood its 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 provider worked with other practices within their primary care network to offer extended access and flu and COVID-19 vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission. Universal care plans were shared across providers, supporting continuity of care between the practice, community services, and secondary care. The practice actively worked with community and voluntary sector organisations to address local health inequalities and had established working relationships with ambulance avoidance teams and PCN hubs. Community drop-in sessions and health education initiatives extended the practice's engagement with the local population beyond the consultation room.

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 contributed to effective practice and research.

The practice had an active learning culture, supported by regular clinical journal clubs, whole-staff meetings, and an open approach to sharing lessons learnt. Clinical staff referenced NICE and local guidelines, and updates were routinely cascaded by management. As a teaching practice, the provider invested in staff development and engaged actively with the primary care network, federation, and local practitioner forums. Staff were encouraged to put forward and test new ways of working, and the practice worked collaboratively with community and voluntary sector organisations to address local health inequalities. Following the inspection, this learning culture was further embedded within a strengthened governance framework, including a structured audit schedule and a quality improvement plan.