Addison House - Haque Practice Also known as Addison House 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 here were some shortfalls in the effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. There were arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used to monitor and improve the quality of care. The provider was working with the local integrated care board to tackle known inequalities. Leaders were implementing quality frameworks to improve equity in experience and outcomes for people using services.

This service scored 61 (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.

Staff told us they felt they could raise concerns and gain support from the leadership team. The provider encouraged staff feedback and staff told us they felt supported. Managers and leaders could account for the actions and behaviours of the staff. Leaders has implemented quality improvement frameworks to address the health inequalities known to the practice.

Staff we spoke with were able to communicate clearly the practice and local area freedom to speak up guardians. There was an in-depth knowledge from staff on the freedom to speak up and whistle blowing policies and procedures.

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.

The GP Partners and manager had an overall responsibility for performance monitoring. There was a lead GP partner for each clinical area. Any concerns regarding a performance concern would be raised in a meeting with the other partners and management team. Leaders told us they took part in the national General Practice Improvement Programme. We found that statutory notifications required for provider registration and incident reporting had not been completed. The practice told us they would ensure these were completed. To date, we have not received these notifications. Following our feedback, the practice demonstrated the immediate concerns had been addressed and had devised risk assessments for areas of concern, for example, legionella concerns not actioned and completion of a fire drill. The provider was working with the local fire service to ensure their completion of fire risk assessments was correct.

Our remote clinical searches identified some gaps within the safe prescribing of medicines, the management of MHRA alerts, long term condition management and access. Although the practice were making changes, these had not been reflected or fully embedded. The practice were making some improvements, however, there was still areas for development required. There were improvements to patient referrals that could be implemented to allow clearer oversight. The concerns we found regarding emergency medicines had been reviewed following our assessment and the practice wanted to work towards addressing these barriers. We asked the provider to complete an action plan for the areas of concerns we identified in their governance processes. The practice was also working with the local integrated care board about premises due to issues with building maintenance that were not completed by the landlord. The provider was also looking at alternative solutions to the maintenance and cleaning contractors due to issues not resolved, despite chasing outcomes.

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.

There was 9 significant events the provider told us had been completed within the previous 12 months. Of these, we saw there had been 4 repeated confidentiality breaches and we saw no evidence that there had been learning demonstrated or that staff had been re-trained in confidentiality. Complaints were responded to, although we did not see escalation details to the Parliamentary and Health Service Ombudsman on all communications, for example, email responses. We asked the provider to complete up to date registration for GP partnership and notification of police involvement as these were not all up to date at the time of our inspection.