During an assessment under our new approach
We carried out this assessment in response to concerns and risk we identified through our ongoing monitoring of the service.
We found one breach of the regulations, in relation to governance.
The practice’s governance arrangements and processes for identifying and managing risks, issues and performance were not always effective. These included risks relating to fire, Legionella, infection prevention and control, medical emergencies, the appropriate and safe use of medicines, and for making sure staff had the skills, knowledge, and experience to carry out their roles safely and effectively.
The systems the practice had in place to make sure staff had the information they needed to deliver safe care and treatment were not always effective.
Patients’ needs were not always assessed, and care and treatment were not always delivered in line with national guidance.
People could not access the care and treatment they needed when they needed it.
Services were not organised and delivered in ways that met patients’ needs, offered individuals continuity and person-centred care, and overcame barriers in accessing care and treatment.
The practice culture did not promote the delivery of high-quality sustainable care.
People told us they felt complaints were not listened to use to make improvements. Staff were not always supported to implement the learning and changes identified in response to significant events and complaints.
Compassionate, inclusive, and capable leadership was not evident at all levels. Staff told us they felt able to speak up but that their voice may not be heard.
There was no clear vision for the practice that had been shared with staff.
In instances where CQC have decided to take enforcement action, we will publish this information on our website after any processes have been concluded.