The Ecclesbourne Practice

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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

The practice worked with an external organisation to support them in developing effective processes to identify, manage, and mitigate risks. Most systems and processes were recently introduced, and they needed further time to embed themselves to operate consistently. Leaders understood the issues, challenges, and priorities for their service. Staff were clear on their roles and accountabilities. A comprehensive business plan was in place to ensure and sustain delivery and develop the desired culture.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders told us that overall, there was a positive open culture which promoted learning and improvement. One of the staff we spoke to said that not all leaders were approachable, and another staff member shared the difficulties they had experienced due to the treatment received from a different leadership team member. We fed this information back to the practice manager, who was receptive to the feedback and told us they were aware of the concerns and shared the steps taken to improve the practice culture so the difficulties within the partnership did not negatively impact staff. Staff told us the practice had recently migrated from a paper-based information system to an electronic system. Staff explained they found it difficult to locate information since the change. We raised this with the provider who stated they would make amendments to document names on the system so that it was more user-friendly.

Leaders understood the challenges to quality and sustainability and demonstrated an understanding of the priorities for the quality of the practice. However, we were not assured that practical action and monitoring had taken place to ensure a high-quality, sustainable practice. Staff told us leaders were visible, and they could access appropriate support in their role.

Staff told us they were encouraged to speak up and raise concerns and felt confident about approaching most of the leaders. They described how leaders had recognised individual contributions from staff and made changes because of their feedback. However, not all staff knew who the Freedom to Speak Up Guardian was within the practice.

There was a freedom to speak champion and related policy, and the provider identified services where staff could raise concerns outside the practice.

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.

The lack of a cohesive partnership within the practice significantly impacted its governance, particularly in terms of the leader’s ability to demonstrate a well-led service. The challenges the practice experienced in retaining a practice manager and recruiting clinical staff further exacerbated this issue. We were not assured that governance processes operated effective because we identified weaknesses in several areas such as staff training, recruitment, and the management of MHRA safety alerts. The provider was open about the challenges and demonstrated the capacity and willingness to improve the service, which was evidenced by the decision to employ an external consultant to support the implementation of new policies and procedures. With many of the processes being recently introduced, there was limited evidence that they were embedded. We found that team meetings were only introduced earlier in the year, and the corresponding meeting minutes contained limited information. At the time of the assessment, there was no formal process to monitor the prescribing of non-medical prescribers regularly; following the assessment, the provider provided us with a plan to monitor such staff in the future. During the unannounced inspection, we found a discrepancy in the practice's clinical staff competencies list, which receptionists use when booking patient appointments. The list did not comprehensively set out the of activities one of the nurses was not trained to undertake. For instance, the provider informed us that the nurse did not give contraception advice, but the provider had not clearly stated this on the list for reception staff. We reviewed a sample of the nurse’s consultations, and there was no evidence they had consulted patients outside of their scope of practice. We also reviewed a sample of the healthcare assistant's consultations. We found that patient group directions were in place for patients who received vaccination.

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.

The staff we interviewed understood their roles and responsibilities and those of others and knew the named leads for key positions. They were aware of where to find guidance when needed. Staff were encouraged to discuss concerns openly and were involved where possible in finding solutions. Staff were aware of the process of raising significant events and were encouraged to do so. Staff members told us they felt supported, commented positively on learning opportunities, and said practice leaders welcomed ideas and suggestions. We heard of examples where suggestions were acted upon. That said, some staff said that not all leaders were approachable. We fed this information back to the practice manager, who was receptive to the feedback and shared the steps taken to improve the practice culture so the difficulties within the partnership did not negatively impact staff.

We reviewed the practice’s patient callback system in response to complaints from patients who stated they received a call back from a GP outside their requested timeframe. The provider told us they operated a late evening callback service for patients; reception staff may have mistakenly added patients who requested a callback during the day to the evening list. The provider agreed to raise the issue with their receptionists to ensure the incidents did not reoccur. The provider had recently introduced regular structured team meetings focusing on learning and improvement, and staff told us they had protected time for learning and development. Staff and leaders demonstrated an understanding of the improvements needed to deliver a safe and effective patient service. The provider had carried out a range of audits, which were discussed during clinical meetings. However, some areas required further improvement, such as closer scrutiny of clinicians' prescribing, ensuring they received comprehensive feedback to support their development, and managing staff training appropriately.