Friarsgate Practice

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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 and inspected against one quality statement, Governance management and sustainability. During our assessment of this key question, we found the practice had not established clear and effective governance, management, and accountability arrangements in all areas. They had therefore not always ensured effective assessment, monitoring, and improvement of the quality and safety of the service placing people at risk of not receiving safe and effective care. This included monitoring the effectiveness of systems used to monitor people’s medicines, maintain accurate healthcare records and provide staff clinical supervision. This is 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. There has been a notable change in leadership this year with a new practice manager and CQC registered manager change . The provider was in the process of introducing changes to ways of working and governance systems. The practice investigated and responded to complaints, significant events and incidents appropriately. There was an embedded system to learn from concerns, complaints and incidents and share learning with the staff team to improve services.

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 told us that they felt supported by leaders and colleagues. However, there was no formal system for monitoring and supervision of staff. Opportunities were in place for training and development and regular team and practice meetings took place. Staff could identify who had specific leads within the practice. For example, the safeguarding children's lead and the adult safeguarding lead. Staff told us that communication was good, and they had opportunities to share their views with leaders. We were told that some of the areas raised as concerns through this assessment had been identified by the practice business lead, for example the lack of clinical supervision and they were working to address these as part of practice improvement plans. However, there was no implementation plan for this process. Following the initial feedback on concerns found within the clinical systems the practice sent through evidence of actions taken to address these concerns.

There was a lack of oversight of systems and processes to monitor the quality of care in relation to the management of patients who were prescribed high-risk medicines, patients with long-term conditions and patients affected by safety alerts. The practice had therefore not identified these risks to patients prior to our assessment so that action could be taken to keep patients safe. Accurate records were not always maintained. Our review of clinical systems found a lack of supporting information within patient records when coded as having a medicine review. Systems to support clinical staff and non-medical prescribers was not in place and there was a lack of formal supervision. The practice had a succession plan in place to replace those who were likely to retire and planned to support staff to encourage leadership in key areas in the practice. A business continuity plan was in place which gave guidance to staff for the preparation of major incidents. The practice had an embedded clinical audit programme. Leaders told us that an annual audit on in-house minor surgery identified risk with results not always being available from secondary care and we saw action had been taken to make improvements following this audit. This demonstrated some monitoring systems had been effective in identifying risks and taking remedial action to improve monitoring systems. The practice had embedded systems to manage and monitor complaints and significant events. We saw evidence to demonstrate the practice investigated and responded to complaints, significant events and incidents appropriately. There was an embedded system to learn from concerns, complaints and incidents and share learning with the staff team to improve services.

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.