Hartog at Twyford

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 found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider had made the required improvements.

During our inspection of this key question, we found the registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

This resulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in the detailed findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, improvements were needed to the practice's risk management systems for monitoring and mitigating the various risks arising from the carrying on of the regulated activities. In particular, the risks associated with fire safety and Legionella. In addition, improvements were needed to ensure that the practice stored records relating to people employed, in compliance with legislation and taking into account current guidance. Procedures should also be implemented to ensure staff are up to date with their mandatory training and continuing professional development. Areas requiring improvement were acted on immediately, where possible, but were not yet embedded. Following the inspection, we received confirmation of the provider’s plans to improve their systems, including employing additional support from the compliance suite already in use.

There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had systems and processes for learning, quality assurance and continuous improvement. However, these were not always effective, and audits were not always undertaken according to recognised guidance. Action is needed to ensure audits of infection prevention and control, radiography and anti-microbial prescribing, where appropriate, have documented learning points, and the resulting improvements can be demonstrated.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

We noted innovative approaches to providing person centred care. For example, the practice provides a sensory basket in the waiting area, stocked with items to support patients who are nervous or have neurodiversity.

Staff feedback was obtained through meetings, surveys, and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, changes have been made to the parking arrangements at the practice to provide more spaces for the patients.

The practice had taken steps to improve environmental sustainability. For example, they turn off lights and electrics when not in use, try to be as paperless as possible by sending estimates and consent by email where appropriate and by actively recycling.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.