Dr C D Lenton & Partners Also known as Ashfield 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 carried out an announced assessment of 4 quality statements (Capable, compassionate and inclusive leaders, Freedom to speak up, Governance management and sustainability, Learning improvement and innovation) under the key question well-led and found: There was evidence of learning and improvement however, leaders did not always proactively support and collaborate with all staff. Governance and management systems required improvement. Information about risks, performance and outcomes was not always shared with all staff to improve care and quality of services. Governance systems were not effective in identifying, mitigating and monitoring risk related to staff recruitment, storage and monitoring of medicines and infection prevention and control. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Mostly staff felt supported by leaders to carry out their role effectively and they felt supported to develop further. However, staff felt that not all leaders were visible and the way in which information was communicated within the organisation needed to improve. Some staff told us they had faced a challenging time, which included not being listened to and they had lost confidence in the leadership team. Leaders told us they had a stable leadership team, where there was mutual support and respect for one another.

There were appropriate processes that allowed leaders to be knowledgeable about clinical issues and priorities for the delivery of high quality services. Although we saw examples of how leaders had responded to staff feedback, there had not been a recent staff survey. This meant leaders may not have been alerted to examples of poor culture that may be affecting the quality of people’s care and have a detrimental impact on staff and consequently there was no action plan to improve. We found gaps in recruitment records that we viewed. Leaders told us they were addressing this as part of the wider organisation review of staff files, which included digitalisation of the records to ensure documentation and information held was complete and accurate.

Leaders told us they had a whistleblowing policy in place and staff had access to a Freedom to Speak Up (FTSU) Guardian. All staff felt there was someone they could go to within the practice if they had concerns or comments for improvement. However, they did not always feel their concerns were acted on. Not all staff were aware of who the FTSU guardian was. Staff told us when they did raise concerns or incidents, they did not always get feedback about any actions being taken to prevent the same happening again.

Processes did not actively promote staff empowerment to drive improvement. Processes did not encourage staff to raise concerns or promote the value of doing so. Staff were not confident that their voices would be heard, leaders would investigate or that lessons would be shared and acted on.

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.

Non-clinical staff had clear roles and responsibilities; tasks were divided up in an organised way and progress was monitored. Clinical staff did not have clear roles and responsibilities for non-clinical aspects of their roles. Staff told us that management of infection prevention and control, stock control, medicines management and other non-clinical tasks for example updating patient group directions (PDGs) were not carried out in an organised way and tasks were not assigned to specific staff. Not all clinical staff were not aware of where backlogs were in performance or what actions were being taken to improve performance.

Governance, management and accountability arrangements required improvement. There were processes to monitor performance and risk and escalate concerns to leaders so that appropriate action could be taken. However, this information was not shared with all relevant staff. The system used to ensure that polices were updated and that polices contained relevant information was not effective. Most policies that we reviewed had not been reviewed by the review date. Not all polices we reviewed had dates of when the polices had been created or a summary of changes to indicate what updates had been made at the last review. Data or notifications were not consistently submitted to external organisations as required. Policies did not provide sufficient information to support staff in doing this. The practice did not have effective processes for the management of risk related to infection prevention and control, storage and monitoring of medicines and safe recruitment of staff. Staff had received and had access to appropriate training to help manage potential risks to patients and the service, such as basic life support and fire safety training. The practice had a business continuity plan to mitigate risks to patients and staff in the event of any disruption to the service.

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.

Clinical staff were supported to undertake further training to support the overall delivery of safe and effective care. Leaders told us that GPs had access to regular continuous professional development sessions. Staff told us if they did raise concerns or areas for improvement, concerns either were not acted upon or not in a timely manner. The practice worked with the patient participation group to make improvements. Leaders used patient feedback to improve quality; however, this information was not always shared with staff or with patients. The practice was working to improve the triage process and access to appointments in general, access to telephones.

Staff and leaders ensured that people using the service, their families and carers had opportunities to provide feedback on care received, and improvements. Leaders worked with the Primary care network (PCN) to improve access and outcomes across the local patient population. There were processes to ensure that learning happened when things went wrong; however, leaders did not always encourage reflection and collective problem-solving. Not all staff were informed of learning following complaints and incidents. While we found that staff had completed required training, not all staff were supported to prioritise time to develop their skills. Leaders did not always encourage staff to speak up with ideas for improvement and innovation and did not actively invest time to listen and engage.