The Hollies 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 reviewed 3 quality statements in the Well Led key question, this included Capable, compassionate and inclusive leaders, Freedom to speak up, and governance management and sustainability. The scores for the other quality statements are based on the previous rating for this key question. We found the practice had experienced challenges prior to the inspection. We were informed there was a high staff turnover and combined with the succession of several different practice managers there was staff uncertainty. Whilst leaders were aware of some of the challenges faced, effective oversight and strengthening of the governance and risk management systems was required.

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.

There was a lack of contingency planning where leaders were unavailable. This had happened in the previous 9 months. Leaders were aware of the impact of some of the challenges on staff and the practice’s performance but felt assured that patient safety was never at risk. They recognised there was low morale and concerns amongst the staff team and intended to improve staff confidence and consistency at the practice. They felt confident in the new practice managers experience and ability to do this. Staff shared in the previous 9 months there was confusion around leadership and decision making. Some staff we spoke with told us that the months prior to the assessment had been hard, especially the high turnover of staff and not knowing exactly what was happening. We were told by some staff that they were unsure of who the leads were as the roles changed so often, although they indicated that there was good peer support amongst colleagues. We were told that staff worked together to ensure that there was no impact on patients and that there were no issues with the quality of care provided. Not all staff were aware if they had access to a freedom to speak up guardian. Some staff told us that they would be happy to speak up if the need arose, some said they would be worried about doing so and others said they have raised concerns but had no confidence that matters were resolved.

There was ineffective oversight and leadership within the practice and management team. There had been a high turnover of staff in the 9 months prior to the assessment including those in management positions. Staff did not always have clear roles and responsibilities although were flexible in their roles in order to meet the needs of patients. We reviewed 4 staff files and looked at appraisals. We found 1 staff member had been working at the practice less than a year and therefore did not have an appraisal that was due at the time of our assessment, 2 staff members had received an appraisal in the previous 12 months and 1 staff member had no appraisal evidence in their file. We spoke with this member of staff who told us that they had received an appraisal in the previous 12 months. Overall, we found appraisals were simple and lacked detail such as professional development. This was an area the practice manager agreed needed improving.

Leaders informed us of the arrangements in place to deal with any behaviours inconsistent with the vision and values of the practice. They told us external support was sought where concerns about staff had been identified. The practice manager informed us there was no freedom to speak up guardian in place at the time of assessment and that this topic had been planned to be discussed at the staff meeting the following week. The practice manager informed us they were putting themselves forward for the role. We were informed that at the time of the assessment, a staff survey had been conducted in an effort to improve staff well-being and morale, the practice had not yet reviewed the results. Staff we spoke with and results we reviewed from a staff questionnaire we issued, displayed that not all staff were aware of a freedom to speak up guardian that was in place.

Overall, leaders and line management of the practice did not understand the requirements of a Freedom to Speak up Guardian that should be independent of the line management chain or GP partnership. The freedom to speak up guardian policy highlighted that the lead GP was the freedom to speak up guardian. There was no external freedom to speak up guardian in place to ensure inclusive and consistent speaking up and driving learning through listening. There were no systems to ensure that staff knew who the Freedom to Speak up Guardian was or how to contact and raise concerns with them.

Leaders were aware of some of the challenges the practice faced and the gaps in the risk management and governance systems. They informed us they were working closely with the Integrated Care Board to ensure that safe and high quality care was being delivered. Some staff we spoke with informed us that the months prior to the inspection had been difficult, particularly due to the high turnover of staff and not being aware of the changes that were happening. Some staff told us they felt unsure who the leads were as the roles changed frequently, they were not always certain of whom to report concerns to and in the times that they did, they were not sure they were being listened to. Overall, Staff felt there was generally good peer support amongst other colleagues. There was mixed feedback regarding the range of meetings that were taking place at the practice and the frequency of these. Some staff understood that specific meetings were taking place whilst acknowledging there had been some gaps, whereas other staff members were not aware nor a part of these meetings.

We found ineffective quality and risk monitoring systems in place to support good governance. There was a lack of effective oversight of staff training and risk management systems. For example, the infection prevention and control audit was due in March 2024 however the action plan from the audit completed in February 2023 did not confirm that all outstanding actions had been completed. The practice did not implement the use of a risk register. Whilst policies highlighted roles and responsibilities including lead roles, these were not always clear amongst all staff, particularly during times of staff absence. Staff meetings had not been consistent therefore did not ensure governance processes always worked and high quality care was consistently being delivered. The practice did not send evidence of their business continuity plans or their information commissioners office (ICO) certificate. There were some recovery plans in place to ensure there was effective oversight and clinical monitoring of patients such as recruitment of staff, liaison with the Integrated Care Board, reinstating regular meetings and audits. We found these required strengthening and embedding into the practices routine ways of working.