Dr H W Ng & Partner Also known as Scott Park 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

Leaders and staff described a positive and supportive culture, with staff reporting they felt able to approach leaders for advice and raise concerns. Staff understood their individual roles and responsibilities and had access to policies and procedures to support them in their roles. However, governance systems were not always effective in identifying, assessing and mitigating risks.

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 centred on providing accessible care to its local population. 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.

Staff told us the service operated an open-door culture, and they felt able to seek advice from the GP and practice manager. Regular clinical and practice meetings were held to discuss operational issues and service delivery. Staff described a positive team culture and told us they felt valued and supported within their roles. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

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 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, or share this securely with others when appropriate.

During the assessment we found environmental, infection prevention and control and fire safety risks that had not been adequately identified or addressed through existing governance processes. Although audits and risk assessments had been undertaken, they had not consistently resulted in timely action to mitigate identified risks which also included DBS risk assessments and privacy risk assessments which lacked effective governance oversight.

Some risks identified during the assessment had also been highlighted at our previous assessment of the service, including fire drills implementation and securing prescription stationery. This indicated learning had not always been embedded or sustained over time. Following the assessment, the service has submitted additional evidence including action plans and an external fire risk assessment to demonstrate how these issues would be addressed. While these actions were positive, they were not fully embedded at the time of this assessment.

Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held some meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders supported staff and met with them to complete annual appraisals and performance reviews. The provider had governance processes in place in relation to the quality statements we reviewed during this assessment, however these were not all effective to identify and manage significant risks.

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.