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

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.

We assessed 4 quality statements from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was good. We found the provider did not have clear and effective governance processes, which supported the safe delivery of care. They had failed to promote a positive culture of continuous learning and improvement. 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 found breaches of regulation for the Well-Led key question and have told the provider to take action.

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.

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

Feedback from staff was mixed about how visible and approachable leaders were and whether they led by example. Some felt that their ideas were dismissed or ignored and that requests for support and advice were not always responded to in a positive way. The practice had commissioned an external organisation to conduct staff feedback questionnaires. We received evidence demonstrating this and that outcomes had been shared with the practice. However, the practice was unable to evidence that they had responded to or made improvements in response to the feedback received. When questioned, practice leaders told us that they had no awareness of the questionnaires and feedback provided by staff.

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.

Feedback from staff indicated that they did not always feel comfortable about speaking up. They felt that concerns were not always handled sensitively and confidentially. Staff did not always feel safe to raise a disclosure in the knowledge that they would not face any detriment from the organisation because of speaking up. Staff felt that if they whistle blew, assumptions were either made or managers would try and find out who raised the concerns.

Following our assessment, leaders responded setting out how they would address these concerns including the use of external organisations to facilitate change in the practice culture.

The practice had a whistle-blowing policy and Freedom to Speak up arrangements with another practice in the primary care network. Staff were aware of how to raise concerns, however examples shared with the assessment team did not demonstrate that the process was used with positive effect.

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.

Staff we spoke with were not always clear on leadership roles within the service. Following the assessment the provider submitted a staffing structure spreadsheet. Leaders told us, as part of their follow up work with the staff team, It was identified that staff were confused with the organisational structure, and some were unsure of who their line manager was and who they went to.

Organisational structure and lines of accountability were unclear. While there was evidence of regular meetings to identify and manage performance, outcomes and key risks, the minutes of these meetings were not always well-documented. This meant the practice had not ensured that clear actions had been agreed and follow up measures put in place to review practice. The practice did not have effective systems to identify all potential risk. For example, the practice had not identified that audits for minor operations had not been conducted. They had not assessed the competence of staff undertaking these procedures. This meant they could not be assured that procedures were conducted by those competent to do so and that patient outcomes were appropriate. Recruitment procedures were not always managed effectively to demonstrate oversight when managing potential conflicts of interest. We also identified that national guidance was not always followed in areas such as significant event analysis, legionella monitoring and systems to support actions arising from MHRA alerts. Following the assessment, leaders submitted information on improvements to the service and steps they are taking to address the shortfalls identified. The impact of these changes is yet to be assessed.

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.

Staff feedback indicated that learning from incidents and complaints was not routinely shared. They were unable to provide examples of innovation and improvement across the organisation and local system. Following the assessment the provider submitted a digital presentation 'quality improvement plan' setting out aspects of practice quality they considered as objectives. However, the time frame element of this presentation did not set out how and when these improvements would be fully implemented and embedded.

There was some evidence that the practice had embraced new ways of working to improve services. For example, the use of the Additional Role Reimbursement Scheme (ARRS) supporting the use of a more diverse workforce, pharmacy technicians and use of remote GPs to review blood test results. However, processes for sharing learning from significant events in the practice were not embedded. Appropriate action and lessons learned were not always identified which meant there was limited scope for improvement.

The practice did not have a quality improvement plan in place to help drive improvements in services.