Archived: Tollgate Health Centre

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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

Leaders and staff did not have a shared vision and culture based on listening, learning and trust. Leaders were not always visible, knowledgeable and supportive, and did not help staff develop in their roles. Staff did not always feel supported to give feedback. Staff did not always understand their roles and responsibilities. There was not a culture of continuous improvement and staff were not given time and resources to try new ideas. At our last assessment, we rated this key question as good at this assessment, the rating has changed to inadequate. We identified breaches of regulation in relation to safe care and treatment, staffing and good governance.

This service scored 32 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Leaders did not have a clear vision and strategy for the future. Leaders were not able to share examples of action to be implemented to ensure a vision and strategy could be achieved. There was no evidence that the future direction, including sustainability or financial viability, had been discussed in any leadership meetings. Staff we spoke with were unclear of the development of the practice vision and strategy. Leaders did not demonstrate an awareness of the projected increase in the local population and evidence of working with partner agencies to address future challenges.

The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not always investigate or report safety events. Safety concerns were not shared with staff. Lessons were not learnt to continually identify and embed good practice.

Information we reviewed demonstrated that people had opportunities to provide feedback, however we were not assured that the practice actively reviewed and followed this up consistently. Managers told us they encouraged staff to raise concerns when things went wrong, however staff were not assured that these concerns were managed appropriately. During staff meetings, we found an inconsistent and ineffective approach to learning. Staff did not feel there was an open culture, and that safety was a top priority. The provider had ineffective processes for staff to report incidents, near misses and safety events and processes to share learning were not embedded. There was an ineffective system to record and investigate complaints, and when things went wrong lessons were not routinely shared to drive improvement. We saw limited evidence of learning from incidents and complaints resulting in changes that improved care for others. Staff told us that their high workload meant that training and learning was not prioritised. This meant staff did not always have the skills and competence to make sure that they met people’s care and treatment needs.

People did not feel they could speak up and that their voice would be heard.

The practice had a freedom to speak up policy in place, this had been updated in the weeks following the onsite inspection. The policy included Freedom to Speak up arrangements with local commissioners, however staff we spoke with were not aware of how to raise concerns. Staff told us they did not always feel able to raise concerns without fear of retribution. There was whistleblowing training in place, but on reviewing the training matrix 18 staff were out of date with their training and there was not an effective system in place to monitor training needs

The service did not always value diversity in their workforce. They did not always work 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. Equality and diversity training was in place, but on reviewing the training matrix 15 staff were out of date with their training and there was not an effective system to monitor training needs. Supporting people with a learning disability training was in place, however 15 staff members training had expired. Adjustments had been made to ensure staff were valued, for example we saw adjustments to working patterns were provided to support staff, however leaders did not demonstrate action to continually review and improve the culture of the organisation in context of equality, diversity and inclusion.

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.

There were issues that we identified during the inspection where it was not clear how these concerns were escalated or what governance systems were in place to identify these issues.

Leaders and managers did not have the skills, training and competencies to support staff effectively. Staff we spoke with were not clear on their individual roles and responsibilities or those of other staff members. Managers had not met with staff regularly to complete appraisals and performance reviews. There had been a significant high turnover of managers within the last 12 months. Staff told us managers were not always visible or sufficiently experienced to support them. The provider did not have established governance processes that were appropriate for their service. Staff could access required policies and procedures; however, we saw examples of policies that did not contain relevant information; review of policies which had not been undertaken in the specified timeframe; were generic and not dated. The nominated lead for the complaints policy had left the practice, the home visiting policy should have been reviewed in May 2024 and the medical emergency guidance document did not contain a review date. Practice meetings were held infrequently and actions arising from these meetings were not always identified and recorded and shared these with staff. Whilst staff understood patient confidentiality and information security, the staff training matrix identified all staff information governance training had expired.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, for example flu and covid vaccination programmes. However, leaders were unable to provide other examples of how these networks identified new or innovative ideas that could lead to better outcomes for people.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Leaders did not demonstrate a good understanding of how to make improvements happen. There was limited evidence of an approach to measure outcome and impact. The practice did not have effective quality improvement plans in place to help drive improvements in services. Processes to ensure learning happened when things went wrong were not effective, for example systems for managing complaints were not effective. Identified learning from complaints was limited and there was no evidence of action plans to make improvements to the service. The Significant Event Policy stated part of the management response and learning from events would be to instigate an investigation that included an audit. We did not see evidence that the audit tool had been used against the 10 significant events identified within the last 12 months. Staff shared concerns during the inspection that quality improvements were not supported by leaders to improve ways of working and patient safety. For example, nursing staff had developed a policy to monitor and action blood test results to reduce the risk of blood clot, however leaders had not engaged with nursing staff to implement this policy. Staff were not supported to prioritise time to develop their skills around improvement and innovation and there was not a strong sense of trust between leadership and staff.