Drs Hussain & Kotekar Also known as New Road 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 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.

The service was in breach of the legal regulations relating to lack of oversight in good governance. We found the practice’s governance systems had not effectively identified or monitored compliance with actions recommended in infection prevention and control audits conducted by the practice, or in external fire safety risk assessments. As a result, improvements had not been consistently implemented.

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. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges including looking for more suitable premises.

The service had leaders 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.

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 with other practices in the primary care network. Staff were aware of how to raise concerns and felt leaders would listen to them.

Leaders valued diversity in their 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. Leaders told us they would address concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff were in place including those with disabilities.

The service did not have clear responsibilities, roles, systems of accountability, or good governance across all areas of practice. Leaders failed to act on information about risk and did not address concerns identified in their audits, particularly those relating to infection prevention and control (IPC). There were no measures in place to mitigate the risk of cross-infection in unclean areas of the building. Additionally, leaders were unaware of the concerns we raised and relied on an external cleaning company without verifying cleaning tasks were completed adequately.

An external fire safety report highlighted several serious issues, including the positioning of fire alarms, which made regular testing difficult. Leaders had not arranged an external fire safety risk assessment for several years, so it was unclear how long the service had been non-compliant with fire safety regulations. Although they were working with the fire service to make improvements, this came at a significant cost which could have been avoided with regular reporting.

Leaders were also unaware of issues affecting people’s dignity in one treatment room. Regular face-to-face meetings with staff had not been provided, as these were difficult to organise with a small team. Staff told CQC most information was shared via an electronic system. While this was efficient, staff felt less connected to leaders and believed communication could be improved. Leaders had already identified this issue and recently implemented a system to ensure non-clinical staff meetings would take place at least 4 times a year. However, staff did have access to up-to-date policies and procedures, and patient confidentiality and information security were taken seriously.

Leaders and staff understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. For example, they shared the outcomes from their diabetes review with a neighbouring practice so they could improve outcomes for their patients. Leaders and staff participated in meetings with the local PCN to share good practice and learning.

Leaders had some focus on continuous learning, innovation and improvement across the organisation and local system. However, they did not always contribute to safe, effective practice due to the conditions of the environment. Staff were active members of their local primary care network and liaised with the intregrated care board which enabled them to meet and share good practice and learning within their local area. Staff received information through electronic tasks which helped them learn more from incidents and complaints.