The Andover Health Centre Medical Practice

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 one quality statement, Governance management and sustainability. During our assessment of this key question, we found the practice had failed to establish effective governance systems, including quality assurance and auditing, systems and processes, therefore had failed to effectively assess, monitor and improve the quality and safety of the service placing patients at risk of not receiving safe and effective care. This resulted in 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 below. During our assessment of this key question, we identified the practice did not monitor mandatory staff training to ensure this was completed in a timely manner and completed to the right level. This meant that staff did not have up to date skills to keep patients safe. Although the practice investigated and responded to complaints appropriately, there was a lack of an embedded system to learn from concerns, incidents and complaints and share learning with staff.

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.

We obtained 11 staff feedback forms during the assessment. Staff described the leadership team as flexible, supportive and approachable. Staff told us that they did not always understand their roles and responsibilities, which led to shortfalls in areas such as record keeping for medicine reviews, workflow to ensure tasks were completed to review test results for people in a timely manner and admin tasks to ensure the summarisation of records were kept up to date. Although leaders took immediate action to start addressing the shortfalls we found, staff were unable to describe how the processes for people who were prescribed high-risk medicines, people with long-term conditions and people affected by safety alerts were routinely reported on to ensure care and treatment was kept up to date. We were shown examples of how people were invited for appointments, including recalls for people with long-term conditions but this was only based on criteria set out in the National Quality Outcomes Framework (QOF) and therefore did not cover all clinical performance reporting. Staff told us that 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. The practice had an employee assistance program in place for advice on issues that might be affecting wellbeing and performance. However, staff told us they felt that the practice could do more to improve staff wellbeing. For example, staff were not always aware of the mental health first aider at the practice to support staff with mental health concerns. Leaders told us they had an ‘open door’ policy for staff to share their views and that the practice manager had been fulfilling the role in place of departed qualified mental health practitioner from December 2023. Staff were not aware of whether there was a freedom to speak up guardian for independent impartial advice. There was a whistleblowing procedure in place.

The provider failed to undertake effective quality and risk monitoring. The provider’s monitoring systems had not identified, prior to our assessment, when people’s care and treatment failed to meet national guidelines. During our remote clinical searches, we identified long-term condition management issues in relation to overdue asthma reviews, people presenting with exacerbations of asthma, diabetes reviews and medication reviews. The practice had failed to identify shortfalls in relation to the management of high-risk medicines, people with long-term conditions, people affected by safety alerts, reviewing of test results and summarisation of people’s care records. As a result, prompt action had not been taken prior to our inspection to protect people from harm. The practice had also failed to identify through their own monitoring the shortfalls identified through this assessment process in relation to a lack of staffing, incidents and complaints and failure to adhere to the Mental Capacity Act 2005 when completing people’s RESPECT forms. This led to shortfalls in people’s care identified throughout this report. A business continuity plan was in place which gave guidance to staff for the preparation of major incidents.

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.