Healey 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 identified a breach of the legal regulations in relation to good governance. Some policies had been developed by a specialist firm but had not been amended to relate to Healey Surgery or the local situation, because of this they were difficult to follow or provide proper guidance. Information was missing from some policies and staff were not following the guidance or using the templates included.

There was no risk assessment or comprehensive audit plan to ensure the service ran as expected and identify areas that needed additional attention. Complaints and significant events were not managed consistently. Not all staff were included in discussions to share learning from events and there was no evidence that the partners were aware of the level of negative feedback.

Succession planning was ineffective as the practice had been without a practice manager since December 2023 and appropriate interim arrangements had not been made.

Processes in place did not demonstrate the partners had full overall oversight of the practice.When things went wrong leaders at Healey Surgery ensured appropriate actions were taken, however management processes did not support sustained learning.

There was evidence of learning and improvement, however processes were not in place to review and embed all learning.

Staff felt able to speak up and said their points of view were listened to and acted on, however, this was not always documented to enable reflection and support continual improvement. Policies did not support staff to raise concerns in an official capacity or to a speak up guardian. The chain-of-command for managing admin staff was unclear. Structures, processes and systems to promote consistency needed to be implemented.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders felt there was a clear vision for the future of the practice. Leaders described discussions with staff about the culture of the service. Leaders and staff discussed the changes as a result of these discussions for example increased choices in the type of consultations and allocating a member of staff to work with women to increase cervical screening.

The provider had developed a mission statement, vision and values for their practice which was sent to us, the document was undated and there was no evidence that this had been discussed or shared with staff other than the leaders.



We saw a positive relationship between all staff, and leaders described a culture based on openness and honesty, however, there was a lack of clear processes for all staff to follow in relation to professional development, supervision, feedback.

Administrative staff fed-back that leaders were compassionate, there was an open-door policy for all staff to approach the partners about concerns. Staff could not confirm they were kept up to date with issues affecting the standard of care such as complaints or incidents at various meetings. We found that such matters were managed exclusively by the leadership team.

Trainee GPs had robust processes in place for influencing and promoting a positive culture amongst clinicians, with formal processes for gaining and responding to feedback and findings from the clinical staff and trainee doctors. The experience of trainee doctors was tightly regulated and reviewed by the Deanery at Manchester University Medical school. Doctors had ample opportunity to comment on their experiences, to relevant leaders and bodies about the quality of clinical care and treatment. Feedback from trainee doctors was overwhelmingly positive and the practice was awarded a gold standard award for the standard of teaching, supervision, learning opportunities and outcomes for the trainee GP’s.

For administration staff formal processes were not so robust. Documents provided did not confirm the level of staff interaction and involvement that was described by staff and leaders. Notes from meetings did not provide evidence that specific topics were always discussed and the opinion of attendees sought.

A process for administration staff to give anonymous feedback about the quality of the service was not in place.

Administration staff had completed a wellbeing mental health checklist. Leaders confirmed they had discussed the results between themselves and were planning to team building exercises. Leaders relied on the open-door policy for honest and useful staff feedback about the quality of care provided.

There were regular administration team meetings, we reviewed the records for three meetings. Standing agenda items for discussion were not in place, meetings were used to give operational information and remind staff about processes. These instructions were not supported by appropriate and accessible policies or standing operation procedures.

Leaders used verbal feedback to update staff however the reasons for change was not explained or baseline information provided. Communications were supported by written confirmation to enable reflection.

Staff who gave feedback explained that the leaders had an open-door policy and confirmed they would be listened to. Staff gave examples of actions taken by leaders as a result of direct feedback.

Not all leaders understood the NHS patients complaints process including the patients right to have the outcome of a complaints investigation reviewed by the Parliamentary Health Service Ombudsmen (PHSO).

Leaders need to improve processes to support staff empowerment and drive equity and improvement. The providers whistleblowing/freedom to speak policy did not meet best practice because it did not provide staff with plain English accessible information about whistleblowing or the Freedom to Speak Up Champion. Neither did the policy provide contact details for the local independent Speak Up Guardian.

Leaders described steps taken to facilitate the diverse needs of staff which included reasonable adjustments related to religious observance, maternity leave and caring responsibilities.

The provider had an equality and diversity policy, and all staff had completed equality and diversity training. The open-door policy for staff development was not supported by robust processes such as an organisational chart detailing who was responsible for different aspects of staff development such as access to training and other opportunities.

A staff survey did not focus on staff opinion about working at the practice which meant leaders did not know whether staff felt fairly treated and equally respected by leaders and other stakeholders.

Leaders confirmed they were keen to support staff and felt that a lack of practice manager had resulted in them getting to know administrative staff better. Administrative staff told us who was responsible for overseeing safety concerns for example infection control or safeguarding.

We were also told that it was always possible to get advice and support from leaders because it was a small team, and all the leaders were aware of what was happening in the practice day to day.

The provider had established governance processes, but these needed to be strengthened. Staff could access all required policies and procedures, however those we looked at were not user-friendly and did not always provide the information needed in an accessible format.

Managers held regular practice meetings with staff, but the records did not always confirm the detail of discussions or identify emerging risks. Managers had recorded some actions from meetings, but subsequent meetings did not confirm what actions had been taken or carried forwards.

Records confirmed that meetings were used to remind staff about the actions they were expected to take but standing agenda items were not in place so information between meetings was reactive, so a picture of how the service was developing was not apparent, and cross referencing showed the corresponding policy did not include the additional instructions.

We saw managers met with staff to complete appraisals, however information discussed for administration staff varied and did not follow a pattern.

The organisational chart did not provide a clear view of the chain of command for administration staff and lacked clarity about who was responsible for monitoring, reviewing and addressing performance and conduct.

We did not get direct feedback from people about partnerships and communities, however minutes from the patient participation group indicated they were involved in developing the practice and suggesting improvements.

Leaders described their engagement with the primary care network and described their involvement to identify new or innovative ideas that could lead to better outcomes for people. Leaders also confirmed they attended multidisciplinary meetings and safeguarding meetings.

We did not receive feedback about Healey Surgery from the ICB.

Processes in place and records confirmed the provider was an active attendee and contributor to the local Primary Care Network meetings. The leaders worked in partnership with the social prescribing team to support community activities that would benefit their patients.

The processes to support the patient participation were well established and appeared to influence how some aspects of the service were developed, for example communication and support to people when the repeat prescription procedure changed.

The patient list has reduced significantly during the past three years and there has not been any documented analysis for the cause of the reduction.

Leaders told us they had updated the telephone system, changed how repeat medicine prescriptions were managed and how appointments were triaged and managed as a result of learning from feedback from staff and people who used services.

Leaders also said they supported staff to take on specific responsibilities if this was of interest to them, for example, taking additional action to encourage women from particular communities to attend for screening or participate in childhood immunisation programs.

We discussed succession planning and stresses caused because the practice did not have a practice manager. The leaders identified that the delay in employing a practice manager quickly was for circumstances they could not control.

The leaders were keen to expand their expertise as a training practice and were working with the Deanery to become a placement for medical students.

Process for recording and reviewing incidents needed to be strengthened. This was because examples of investigations completed did not relate to or follow the key points in the reporting incidents policy made available at the practice.

There was an active patient participation group (PPG) who represented the views of people using the service. Meeting records indicated that the PPG were kept up to date and their opinions sought about changes such as the improved telephone system and new ways of ordering repeat medicines.

Processes in place did not support the leaders spoken ambitions to promote a positive culture of openness and honesty, to ensure stakeholders were listened to and action taken to consistently promote safety, innovation, high- quality care and stakeholder satisfaction. This is because high-risk activities and situations were not assessed or mitigated.

The providers business continuity plan was not robust as it had not been reviewed when the recruitment process for a replacement practice manager was repeatedly unsuccessful.

Key policies such as the health and safety policy; risk assessment policy and complaints policy, were not accessible and did not relate to the service.. For example, the information provided to us about recording serious incidents did not match the policy. The health and safety premises risk assessment did not include a risk rating in any area so high-risk activities listed were not assessed and mitigated as needed.

Processes to manage feedback from people who used services were not robust. We found the leaders were unaware of negative feedback from the most 2024 NHS GP patient survey.

The leaders had conducted a patient feedback survey but the findings in the resulting report were unhelpful as key information was missing for example: the date of the survey, the questions asked and responses.

How changes were planned and prioritised was unclear as there was no overarching risk-register with monitoring and audit plans.