Ferryview Health Centre GP 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 practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection in 2019 we rated this key question as good. At this assessment the rating has changed to requires improvement. The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. We also found the provider did not have a clear process to identify, monitor and mitigate risk. The practice did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider 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.

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.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us that leaders were generally visible and approachable. Leaders told us that they worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. There were clear lines of responsibility to support capable and inclusive leadership. We noted that some clinical staff had several key areas of responsibility, at a practice with a large list size. Leaders told us that this workload was manageable, although some staff mentioned that lead clinicians had very high workloads. The practice had put in place job descriptions for all staff and had ensured staff were aware of their roles and responsibilities.

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 provider did not have a clear process to identify, monitor and mitigate risk. Risks were managed as they occurred, however there was no risk register in place to proactively identify and mitigate risk. In the absence of a risk register, it was unclear how the practice was monitoring both risk mitigation, and subsequent learning and improvement. The provider carried out pre-employment checks, however we found information on the immunisation status of staff was not always collected as part of these checks. We reviewed 5 staff records and found there was not record of immunisations for 2 non-clinical staff. There was no record of diphtheria, tetanus or polio immunity for 2 clinical staff. The provider had failed to identify and mitigate the potential infection control risk of staff members not having immunisation against infectious diseases. Following our assessment, the provider shared details that 1 of the identified members of non-clinical staff had vaccination records in line with current guidance. We found improvements were required in relation to the management of risks relating to: management of patients with long term conditions; patients prescribed medicines requiring monitoring; safety alerts; emergency medicines; safeguarding register; and staff immunisation records.

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.

The practice did not always focus on continuous learning, innovation and improvement across the organisation and local system. Leaders explained there was a process of continuous learning, improvement and innovation in the practice. They explained that audit was to form a key part of practice learning as it led to change. However, we noted that audits and reviews that leaders told us had been undertaken had not provided assurance that safe and effective care were being provided. Complaints and significant events were reviewed, and learning shared within the practice and externally.