The OM Surgery

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• 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 were not assured that the practice had clear and effective governance, management, and accountability arrangements. Management acknowledged that standard policies and procedures needed updating. Not all staff we spoke to understood their roles and responsibilities and described poor management oversight by leaders at the practice. We were not assured that a robust complaints process was in place. We were not assured that all patient records were stored securely. There was limited evidence of a robust auditing process, including clinical audit. Overall, most staff felt happy to raise concerns at the practice and described a supportive culture within their immediate teams. However, not all staff felt that management acted on their concerns and there was limited evidence of a consistent approach to listening to concerns from staff.

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.

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.

Most staff were aware that the practice manager and lead GP were the designated Freedom to Speak Up Guardians. They told us they felt they could raise any concerns but sometimes management did not act on them. The lead GP acknowledged that as a small surgery there should be provision within the whistleblowing policy for staff to raise concerns outside of the practice, for example, with a buddy practice in the PCN. Most staff were aware of the values for the surgery, and we observed posters detailing those values, however there was a lack of knowledge about the practices vision to become a training practice in the future.

There were policies in place to support speaking up, for example whistleblowing and disciplinary procedures. However, the whistleblowing policy did not have reference to how staff could raise concerns externally.

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.

Leaders told us the premises were owned by the previous provider and the contract to provide NHS services had not yet been finalised. They acknowledged the concerns raised throughout the assessment and told us these would be addressed immediately. The lead GP worked at the practice Wednesday morning and all day on Thursday. He told us he provided support remotely by completing tasks within the clinical system. The practice manager worked part-time hours, providing 10 hours a week at the practice. She told us staff could contact her on the telephone when she was not at the practice. There were plans to recruit a deputy manager internally from June 2024. Although leaders described a culture of transparency, with an open-door policy for staff to raise concerns, some staff did not feel listened to. Staff told us they were concerned about overall effectiveness of management given their limited time on site. However, they felt there were clear roles and responsibilities to enable them to carry out their duties. Staff were aware of the value of the practice but did not know of succession plans including plans to become a training practice. The ICB were due to undertake a performance review visit following the change in provider. They were not aware of any clinical performance concerns relating to the practice.

The lead GP had recently taken over the practice as a sole provider; however the appropriate applications to change provider with the Care Quality Commission had not been submitted at the time of our assessment. The statement of purpose was incomplete and the registered manager status remained with the previous provider. Therefore the provider was not meeting statutory and regulatory requirements. Policies and procedures were not managed effectively. For example, the business continuity plan contained out of date contact information. A revised document was submitted after our assessment. A revised Disclosure and Barring Service (DBS) policy was submitted following our assessment, however, it still did not address how staff would be risk assessed annually, in line with their policy. We requested but did not receive a clinical governance policy demonstrating how test results, discharge letters and referrals were managed within the practice. We requested but did not receive a policy on practice oversight of other staff not directly employed by the practice who have access to patients or their records. There was no evidence that the practice held regular meetings with the primary care network (PCN) who employed and supervised staff in additional roles who supported the practice. There were no documented succession plans or business plans to demonstrate financial and workforce sustainability. The practice manager had started a quality improvement project on access; however this was still at early stages.

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.