Pudding Pie Lane 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 assessed 1 quality statement in the well-led key question and found areas of good practice but also identified some systems and processes were not always effective. Governance systems and processes existed, however, we found examples where they were not fully effective or sufficiently embedded throughout the practice. Systems to provide the practice with the oversight of risk had recently been introduced and required further embedding.

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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Staff were clear about their roles and responsibilities and were proud to work for the service. We reviewed the minutes of a selection of regular team meetings and found there were established processes to discuss risk, performance, and concerns. Not all staff knew what or who their Freedom to Speak Up Guardian was (someone who supports workers to speak up when they feel that they are unable to in other ways) however, they told us they felt comfortable raising concerns with leadership who were visible and approachable. A member of staff told us they were carrying out reviews for long term conditions but had not completed appropriate formal qualifications in those conditions and competencies had been reviewed by a member of staff who had not completed relevant training. Leaders told us they had evidence these members of staff had completed training and submitted a sample of evidence but not for all the members of staff we had identified.

Staff had access to policies and procedures, which were reviewed on a regular basis. The practice had introduced a spreadsheet providing oversight of workflow, risks and actions. Following our clinical searches, the practice added further areas of risk so they can track and quantify their improvements. This recent oversight was implemented to support new processes to ensure patients were reviewed and monitored in line with national guidance. However, whilst monitoring had taken place, it was not always recorded on the practice’s own patient record system. Therefore, there was no evidence this monitoring had been checked before prescribing medication. The practice had a system to ensure they received medicines safety alerts however, we found the process to manage the alerts was not always effective. The practice had emergency medicines and equipment onsite that had been appropriately risk assessed. Leaders told us daily supervision of non-medical prescribers took place with a GP mentor, but the practice was unable to provide evidence of formal assessments or monitoring on their prescribing practices. The practice did not have an effective process to evidence staff had completed training in specific long term conditions to support staff to carry out effective reviews.

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.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.