East Shore Partnership

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 assessed and inspected against three quality statements, Shared direction and culture, Freedom to speak up and Governance, management and sustainability. During our assessment of this key question, we found the practice had failed to establish clear and effective governance, management and accountability arrangements. They had therefore failed to effectively assess, monitor and improve the quality and safety of the service placing people at risk of not receiving safe and effective care. This included failure to monitor completion of the fire risk assessment actions. We identified a lack of monitoring in relation to infection prevention and control (IPC) practice. Hazards posed by the environment had not been assessed and effective control measures put in place to protect service users from harm. During our assessment of this key question, we identified the practice had not identified that they did not have an effective system in place to ensure staff training and supervision was kept up to date. We identified an unquantifiable backlog of summarisation of records for people without an action plan in place to address the shortfall. This meant that records were not kept up to date to inform effective treatment decisions. The above evidence resulted in a breach of regulation 17 Good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The practice were working towards building a positive culture for staff in the workplace as part of their values, which included health and wellbeing amenities; encouraging staff to share concerns and reviewing feedback to improve the service.

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.

The provider had a mission statement which was available on the practice website that described the vision and values, aiming to provide the best possible outcomes and a positive experience for both staff and people using the service. We saw example of policies and procedures that had been developed to give guidance on managing relationships and communication at the workplace, which outlined human resource information such as conflict resolution, disciplinary and grievance processes. There was an equality and diversity policy in place which defined the commitments of how the provider ensured people with protected characteristics were treated equally and fairly. The practice had completed a staff survey in March 2024 which had 39 responses. Information such as trends and proposed improvements were reviewed with an action plan in place to incorporate a ‘You said, we did’ noticeboard, to develop an open and collaborative culture.

There were 50 staff members employed to work at the practice. We spoke with 18 staff members and received 25 staff CQC questionnaires. Staff members told us there was a friendly and supportive environment to work in. Managers and GPs were approachable, and staff felt supported by the whole team. They commented positively on the opportunities to learn and develop. Leaders were receptive to the staff feedback we shared with them.

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.

Staff told us they were encouraged to speak up and felt they were able to do so. Where required staff said they discussed concerns openly. Staff told us they were aware of the process to raise significant events and encouraged to do so. Staff were able to identify either who the Freedom to Speak Up Guardian was or how to find further guidance for raising formal concerns independently.

There was a whistleblowing policy in place outlining the process for escalating concerns, which included raising concerns to public bodies and regulators as well as the Freedom to Speak up Guardian. Contact details were available for the Freedom to Speak Up Guardian who held a leadership role at a practice within the Primary Care Network (PCN).

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 we interviewed did not always have a clear understanding of their roles and responsibilities and that of others. This included responsibility for the fire risk assessment and monitoring of environmental risks. However, staff told us they were aware of where to find guidance when needed, including policies and procedures. Leaders told us there was on-going recruitment for administrative staff who would assist with ensuring people’s records contained up to date information.

The practice’s monitoring systems had not identified, prior to our assessment, all of the health and safety risks in the practice. The practice had failed to identify shortfalls in relation to the oversight of device management, fire safety, legionella and infection risks, placing people at risk of harm. The practice was in the process of transitioning between training records systems at the time of assessment. The practice had not monitored training that was deemed mandatory as per practice training policy to ensure this was completed in a timely manner. This meant that all staff did not have up to date skills to keep people safe. We identified a lack of regular, documented clinical supervision for non-medical prescribers, instigated by the supervisor. The provider’s monitoring systems had failed to identify regular audits of prescribing and the review of care provided by staff did not take place to ensure treatment was safe and in line with national guidelines. We identified an unquantifiable backlog of summarisation records for people, we estimated there were approximately 500 records. There was a risk that staff did not have the most up to date clinical information to inform treatment decisions and care planning. The practice had also not identified their recruitment and Human Resource (HR) records were not always kept in line with practice policy. The practice had not historically raised business and clinical risks on a risk register or quality improvement plan with an action plan to implement controls to prevent future incidents. We found the practice had started to record risks such as a lack of hot water issues during the on-site visit.

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.