The Osmaston Surgery Also known as Dr I R Shand & Partners

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

There had been some improvements in how well-led the practice was since our previous assessment. An improvement plan had been developed following our previous assessment and there was a system of monitoring progress against the plan. Staff were supported through a Freedom to Speak Up Guardian if they had any concerns. Structures to support governance and mitigate risks were now in place and a suite of policies had been developed to support this. The practice had started to work collaboratively with partners and communities. However, during our assessment of this key question, we found concerns in the quality statements for shared direction and culture; capable, compassionate and inclusive leaders; workforce equality, diversity and inclusion; governance, management and sustainability; and learning, improvement and innovation. This resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

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.

Leaders told us they operated a no-blame culture within the practice. Staff feedback regarding the culture within the practice was mixed. Some staff told us that the culture within the practice had improved. They described the culture as friendly, helpful and non-hierarchical and they knew who to go to for support in lead areas. Some staff told us there was a blame free culture within the practice and that leaders listened to suggestions and were open to making amendments when systems were not working well. However, other staff described the culture within the practice as controlling, restrictive and blameful. Staff expressed concerns regarding communication between leaders and staff. They told us that staff were not always fully consulted with when changes were implemented and they were told to do things a certain way without an explanation of why. They told us leaders were not open to staff feedback or suggestions regarding improvements. Several staff members told us that staff were not allowed to speak with leaders about issues within the practice. Staff were not aware of the practice’s vision statement, mission or values.

The values and objectives for the practice were outlined in the practice’s statement of purpose. The practice’s aim was to deliver high quality primary care services with the available resources to all patients in a safe, responsive and effective way, in an environment which was friendly, welcoming and maintain the core values of traditional general practice. Their objectives focused on safety and quality, developing staff, communicating effectively and sharing information to involve, empower and support each other to support staff to work collaboratively. The provider had developed an improvement plan following our previous assessment. Progress against the action plan was rated and reviewed monthly with the local Integrated Care Board.

Some staff told us that leaders understood the challenges within the practice and had taken some action to address them. However, other staff felt they were actively discouraged from making suggestions regarding improvements that could be made. Staff views were mixed regarding if leaders were visible and approachable. Not all staff felt well supported or that the leaders were approachable and friendly. Non-clinical staff felt able to approach any member of clinical staff for support and guidance. However, following our onsite assessment a member of staff contacted us to inform us that they could no longer tolerate the blame culture within the practice.

There were systems in place to ensure that staff were recruited in line with legal requirements. Leaders demonstrated they understood most of the challenges to quality and sustainability. They had identified the actions necessary to address these challenges through an action plan which they shared with the CQC, although not all of the actions had been fully embedded into practice.

Staff knew how to access the policies relating to whistleblowing and the Freedom to Speak Up Guardian.

There were policies in place to support staff to speak up if they had any concerns. Details of the Freedom to Speak Up Guardian were on display within the practice.

Staff told us that the practice operated a zero tolerance procedure and that systems were in place to request assistance in an emergency. Patients received a warning letter if their behaviour was unacceptable. Feedback from staff indicated that not all staff felt they were treated equally or encouraged to be involved in the running of the practice. They told us the leaders were controlling and not open to feedback or suggestions regarding improvements. They also told us they were prevented from carrying out their role in full or to the best of their ability and this impacted on their wellbeing.

There were systems in place to ensure that staff completed training in equality, diversity and inclusion. We found no evidence of discrimination in the recruitment of staff.

Staff told us they were aware of how to access the practice’s policies to support them in their roles and attended monthly team meetings. The practice manager kept staff up to date through a staff newsletter. Most staff told us they were clear about their roles and responsibilities. They told us that day to day service delivery was overseen by the practice manager and leads for reception and administration. The duty GP was responsible for clinical checks. There were systems in place to monitor safety within the practice for example, vaccine fridge temperature monitoring checks. Clinical care was supported by the use of clinical templates, which incorporated up to date guidance and safety netting advice. Clinical staff told us they followed prescribing guidelines and shared care agreements were in place. Leaders told us that staff were aware of their roles and responsibilities and had a clear understanding of the rationale behind the ways of working.

There were governance structures and systems which were regularly reviewed. For example, an action plan to address concerns identified at our previous assessment. A suite of policies was in place to underpin governance arrangements within the practice. However, we found that the provider had not always acted in line with their policies, for example complaints. A business continuity policy was in place to support the practice to continue to deliver services in the event of an unplanned disaster such as loss of domestic services, a pandemic, service outages, or other potential threats. The provider had not made an application to register a registered manager or the regulated activity maternity and midwifery services with the CQC which was a legal requirement.

A member of the previous Patient Participation Group (PPG) told us that a meeting was held in April 2024 between themselves and the practice manager. The meeting looked at how they could reinstate and increase the membership of the new PPG for example, the use of social media and the development of a leaflet informing patients of the role of the PPG. They discussed how the PPG could engage with vulnerable patients and promote health services.

Leaders told us the practice collaborated with the local primary care network and worked with Derbyshire Health Inequality Partnership to promote health care screening and increase the uptake of childhood immunisation. Staff told us that the Freedom to Speak Up Guardian had visited the practice to deliver a training session about their role and support on offer.

A representative of a care home where the practice provided care and treatment told us that these systems to support collaborative working had been reviewed and there had been a significant improvement. Feedback from a representative for the Derbyshire Health Inequality Partnership was extremely positive and they told us the practice had embraced partnership working with them to improve outcomes for ethnic minority groups.

Systems to work in partnership with the Patient Participation Group (PPG) had ceased in 2020. There were plans in place to reinstate the PPG to support patient partnership working. There were systems in place to work in partnership with the Derbyshire Health Inequality Partnership to improve the uptake of cervical screening and childhood immunisations.

The practice participated in the national General Practice Improvement Programme (GPIP) and the practice manager acted as the facilitator. They told us the process had been driven by reception and administration staff to look at and find solutions to the issues around access. A plan was in place and the practice was working through the proposed improvements. The practice manager told us they had undertaken a skills assessment for staff to identify potential gaps in their knowledge and training and developed a human resources and training plan. This included a clinical system training recovery plan. They had developed a training skills matrix for the clinical system had been developed.

Systems and processes for tracking complaints and significant events had been put in place. The provider used the learning from these to drive improvements. The GPIP was used to review the results of the National GP Patient Survey, which highlighted issues with access and the telephone system. In response to the findings, the practice amended the process of booking appointments to support patients to only book appointments over the phone or online. The practice used text messaging to send out links to support patients to book appointments online. The practice was in the process of reviewing the responsibilities of administrative and reception staff to ensure a fair and equitable distribution of work. The provider showed us 3 audits they had completed to improve the care for patients. However, there was no recorded analysis or learning outcomes identified and acted on.