Archived: Seaforth Farm 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

At our last inspection we found that leaders had not fostered a positive culture where staff felt they could speak up and their voice be heard. Information about risks, performance and outcomes was not used or shared effectively to improve care.

We identified a repeat breach of Regulations 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as set out in the warning notice issued on 4 September 2025. The provider was required to be compliant by 6 December 2024.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last inspection feedback from staff and other sources indicated discomfort with some aspects of the management culture which included allegations of bullying and harassment, breaches of staff confidentiality, shouting and public humiliation.

The practice was unable to provide assurance that they had effective processes to act on or escalate allegations of poor culture. Processes did not ensure appropriate actions were taken to address or prevent bullying and harassment for all practice staff.

At this inspection we found that leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. We saw leaders had not acted on concerns raised by staff about a significant backlog of blood tests results and the consequent risks to patient safety. The GP partnership did not work collaboratively, which had led to an inability to make critical decisions which had significantly impacted on patient safety, care and treatment.

Feedback from staff at this inspection indicated an ongoing discomfort with the management culture. They were not confident that concerns raised would be dealt with appropriately or effectively. The practice was still unable to provide assurance that they had effective processes to act on or escalate allegations of poor culture.

At our last inspection staff told us they did not feel they could speak up and that their voice would be heard.

At this inspection we asked staff to complete a confidential questionnaire, and we carried out staff interviews. Nine out of 15 staff who completed the questionnaire told us they were still not confident about speaking up without fear of retribution.Some staff told us they continued to experience or witness staff being bullied.

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.

At our last inspection we found the practice 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, or share this securely with others when appropriate.

At this inspection, we found no evidence of improvement. Staff remained unclear about roles and responsibilities and told us that frequent changes to systems and processes led to confusion and lack of clarity. There was no evidence that the practice had effective oversight of the prescribing practices of non-medical prescribers, and the competence of clinicians undertaking minor surgery.

There was a lack of accountability and functional decision making with the partnership in the practice. One of the partners told us that they had disagreed with a partnership decision to relinquish the services of locum GPs who had been dealing with the blood test results. However, there was no evidence of this in the minutes of the partnership meeting where this had been decided.

The practice failed to act on information about risk. They had not acted on the emerging risks to patient safety arising from the known backlog of blood test results. The practice only put measures in place to deal with this, when told to take action by CQC. The practice had failed to review results in line with its own protocols for viewing and acting on urgent test results.

There was limited evidence to show that leaders and managers supported staff. The practice failed follow practice procedures for managing employee performance. We saw evidence that staff members had been invited to performance meetings without due process being followed. There was no evidence that issues had been identified during routine appraisals, complaints, audits, or colleague feedback. Steps to be taken at the informal stage had not been observed. Letters to employees inviting them to performance review meetings did not include their right to be accompanied by a trade union representative or colleague. This was not in line with practice policies or national legislation.