Northfield 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

At our previous inspection, the practice was rated inadequate at providing well-led services because systems and processes in place were not working as intended, overseen effectively, or structured in a way that enabled the provider to fulfil their responsibilities to the practice population. At this assessment we have rated the practice as requires improvement for providing a well-led service. We found that there was a strong emphasis from senior leaders for learning and continuous improvement, this included inviting external speakers to team meetings and training events. Governance structures and systems were in place although some required review, this included changing and improving some monitoring systems. Despite these improvements, systems and processes were newly formed and would take time to fully embed and show sustained improvements for both staff and patients.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us that were possible all staff were involved in decision making when appropriate, however feedback received from staff indicated that not all staff believed they were involved in this process.

All staff had received equality and diversity training. The practice had carried out work to identify hard to reach communities and had developed an action plan to improve healthcare for this group of patients. The majority of staff feedback was positive around the culture of the organisation, however not all staff believed they were involved in strategic planning of the practice.

Staff told us they received regular appraisals and were given opportunities to discuss development and training needs during their appraisal. Leaders told us they had an open door policy. The majority of staff told us they felt they could approach leaders at any time if they required support. Leaders told us they had discussed succession planning. The majority of staff reported a positive working environment.

Appropriate recruitment checks were completed for staff. We reviewed 3 personal files and found appropriate checks had taken place including disclosure and barring (DBS checks). Records showed staff had received an annual appraisal or had a date scheduled. The practice used a spreadsheet to monitor when appraisals were due so these could be scheduled in advance.

Feedback from staff indicated that not all staff were aware that the practice had a freedom to speak guardian. The majority of staff told us that they felt they were able to approach leaders to raise concerns however not all staff felt like they were involved in decision making as they would have liked.

We saw that the practice had access to a freedom to speak up guardian, and there was also a whistleblowing policy. There were posters displayed in the practice with signposting information for support, this included information about the freedom to speak up process. The practice had QR codes on noticeboards that staff could use to raise comments or concerns anonymously. Although systems in place had improved from our previous inspection, we did not have assurances that these improvements were fully embedded or would be sustained, as feedback from staff indicated that not all staff members understood the freedom to speak up process.

Staff told us they had completed equality and diversity training. They also told us they were able to attend practice meetings. Leaders told us they had an open door policy. The majority of staff told us they felt they could approach leaders at any time if they required support. However, not all staff felt like they were included in decision making processes.

The practice had a diverse workforce in place. Equality and diversity training was part of the mandatory training for staff. We saw examples of how the practice had regular meetings with staff.

Staff knew how to access practice policies. All practice policies were accessible on the practice’s computer system. Leaders told us that the practice reviewed policies annually. There were named leads in place for key areas and staff were clear about their roles and responsibilities.

Clinical searches we carried out on the practice’s clinical system showed good patient care for long term conditions such as asthma and chronic kidney disease (CKD) however diabetes care required further improvement. We completed a search for women of childbearing age on teratogenic drugs. We identified that patients were sent a generic non-specific text to warn about the risks of this medication. We discussed this with the provider, they provided evidence to show this had been updated to provide patients with more information about the risks associated with this type of medicine. We also found that structured medicine reviews required improvements for patients with diabetes and also those taking gabapentinoid medicine. After the assessment the practice provided evidence of an updated medicines management policy following the clinical searches we ran. However, as these systems and processes were recently developed we did not have assurances that they were fully embedded to demonstrate improvement or positive impact to patient care. The provider had a business continuity plan in place. There were effective arrangements for identifying, managing, and mitigating risks.

People were able to access support at the practice rather than be referred elsewhere. For example, a mental health worker was available through the primary care network clinics. The practice had recently restarted their Practice Participation Group (PPG), we saw that when this restarted there were 3 members but at the latest meeting the PPG had increased to 12 members, however, as this was newly formed and would take time to fully embed and show sustained improvements. Results from the National GP Patient Survey in regards to the overall experience of the GP practice was considerably lower than local and national averages.

Leaders told us they used the PPG meeting to include guest speakers such as Well Doncaster, Autism Plus and Mind Doncaster.

The practice worked with commissioners. For example, they had carried out some quality improvement work which allowed the Integrated Care Board (ICB) to make cost effective switches in medications. The Integrated Care Board (ICB) told us the patient experience manager had done a lot of work to improve patient engagement. Weekly text questionnaires were sent out to patients after their appointments to gain feedback, this feedback was more positive than the National GP Patient Survey showed.

The practice had action plans following the results of Friends and Family test and the National GP Patient Survey. This included employing more reception staff to answer calls, having a telephone escalation policy, and updating the telephone system in the future. The practice had recently recruited a patient experience manager who collected feedback from patients to improve services. The provider sent out weekly text questionnaires to patients after appointments. The practice received between 250-300 responses per month, this feedback was more positive than the National GP Patient Survey. This was also reflected in more positive results from The Friends and Family test with a positive satisfaction result of 84%

Staff told us they attended regular training sessions where guest speakers were invited to clinical meetings and training events. This included speakers on chronic kidney disease (CKD). Before this assessment the provider sent us a clinical audit on managing CKD. When we ran our clinical searches, we found that recall systems and monitoring of these patients was good. Staff told us they had completed further clinical audits on dementia and diabetes.

We saw the practice had undertaken a number of 2 cycled clinical audits. Clinical searches showed that asthma and CKD care were improved following these audits. The practice had an action plan in place to increase uptake of cervical cancer screening and child immunisations, however, the uptake for these were under national targets. We saw evidence of monitoring data, for example the practice looked at telephone call monitoring logs and was able to benchmark itself with other members of their Primary Care Network.