The Orchard 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 the practice 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.

As concerns remain regarding governance and oversight, we found the practice was in breach of legal regulation in relation to good governance.

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 practice had a shared vision, strategy and culture. Staff and leaders understood the challenges and the needs of people and their communities.

The practice’s vision and strategy was defined in the practice ethos statement which details the partnership between patients and staff, based on mutual respect, holistic care, continuity and learning. 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.

As a small practice, leaders had identified the need for several staff to be multi-skilled in order to work flexibly to meet demand, and we saw staff were able to progress in their roles as a result. For example, a receptionist had trained in phlebotomy and is now undertaking the care certificate to work as a healthcare assistant.

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 practice did not have clear systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. However, the practice had clear roles and responsibilities.

Systems to ensure staff were up to date with necessary training were ineffective and gaps were found in training records for clinical and administrative staff. Oversight processes had not been effective in identifying or managing this risk, to keep people safe. We identified concerns with how information was collated around training to allow clear management of incomplete or outdated training. This meant that leaders were unable to assure themselves that staff had all the required skills for their roles, or that their knowledge had been updated to include current practices or guidance. Since our visit, evidence of actions being taken to address these concerns has been received.

Governance processes were not fully established or working as leaders intended. The practice did not have a robust system for recruitment to ensure that people were employed in line with legislation. Employment records contained gaps including criminal records checks for staff members who had already been employed for several months, despite the practice policy requiring these to be in place before employment commenced. This meant that leaders were unable to verify the safety of staff employed to deliver their services to the public, or assure themselves of the suitability of staff for their intended roles. Following the assessment, the provider submitted a plan for actions it intended to take, and the timescales for completion, to improve processes for safe recruitment

Processes to ensure all staff were appropriately immunised for their roles were also not effective or in line with national guidance. Records reviewed for staff were incomplete and the full immunisation statuses of staff were not routinely sought. This meant that leaders were unable to assure themselves that staff were protected from the risk of infection or from spreading infection to others. As the risk of infection was not being identified, steps could not be taken to mitigate risk, to comply with regulations. The practice leaders have since provided a plan of actions they intend to take, to address this concern.

Staff could access practice policies and procedures, and were able to explain the contents and storage locations of policies relevant to their roles. Some of the policies reviewed during our assessment did not contain all the required information and were presented in a format that did not identify their source or review date. For example, the recruitment policy did not detail which documents needed to be retained. This meant that policies may not have provided guidance for staff that was current or appropriate, and care may not have been delivered in line with legislation. Since our visit, leaders have undertaken work to update and formalise policies into a standardised format for ease of use.

These findings demonstrated that governance systems and processes were not always effective or operating as intended, to ensure risks were identified, monitored and mitigated. Leaders were open to our feedback and have acted to address the concerns raised. Whilst the practice has provided details of recent improvements to their governance, changes are not yet embedded or sustained.

Staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the practice. Leaders clearly 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. Staff submitted data and notifications to external agencies as required.

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.