J P Ward & Associates

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 found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure they have been put right by the provider. During our assessment of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided. 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.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

We found staff to be open to discussion and feedback. The practice staff and provider demonstrated a commitment to developing a transparent and open culture in relation to people’s safety. There was an established, effective staff team committed to the providers ethos and delivering excellent patient care. Staff stated they felt respected, supported and valued. They were proud to work in the practice and found leaders to be supportive and approachable. Feedback from staff was obtained through meeting and informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Staff told us how they collected and responded to feedback from patients, the public and external partners.

We noted that systems and processes were operational at the service but not fully embedded across all the staff team or areas of the service. Where the assessment identified areas which required improvement these were acted on swiftly. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. We found that these were not always effective in ensuring governance and oversight and risk mitigation tasks were completed in line with guidance. Systems to ensure that audits were completed in line with guidance were not effective. We found that information was gathered to develop audits for radiography and infection prevention and control (IPC), clinical records and antimicrobial prescribing but this was not always analysed to promote development and improvement. Monitoring of recruitment files did not identify that required pre employment information was not available for all staff. Oversight procedures for completion of required monitoring checks of the availability and suitability of medical emergency equipment and medicines, fire detection and suppression systems, flushing of dental unit water lines and NHS prescription pad security were not effective. We noted that the providers assessments and mitigation of risk for business continuity were very detailed, comprehensive and effective. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV). The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations (GDPR). The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.