Evergreen 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

During the assessment we reviewed policies, spoke with staff, and undertook observations while on site. We found the following: • While governance systems and processes existed, we found examples where they were not effective or sufficiently embedded throughout the practice. • There was a lack of clear governance between the practice and the Primary Care Network (PCN). Specifically arrangements regarding staff employed by other practices who also worked at the practice. • Processes to manage significant event activity did not ensure learning was shared or events were investigated completely. • Systems to provide the practice with oversight of risk existed but did not contain control measures to manage or mitigate risks

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 discussed the management of significant events (SEA’s) because our review of significant event recording documents found they failed to fully demonstrate what had happened, the subsequent investigation and the changes resulting from the event. We also found a member of staff unable to provide an example of a recent SEA and some staff were unclear about the process to raise an incident. We were not assured the practice had an effective or embedded system to manage SEA activity. We were told the practice was in the early stages of introducing new processes in the practice to record events and to give clearer oversight to management. We found 4 of 7 Patient Group Directions (PGDs) had not been correctly authorised and discussed this with the lead GP. The practice committed to reviewing all the PGDs in operation and the process followed by the practice to ensure all were correctly authorised in the future. During our onsite visit we highlighted that the practice did not have defibrillator pads for children below the age of 8 to the leadership and management. We also found the practice did not stock an emergency medicine to treat the effects of opiates. We asked whether these decisions had been risk assessed and found they had not been. After the site visit the practice reviewed guidance to confirm the appropriateness of their defibrillator and confirmed that the device was suitable for use by children below the age of 8. The practice had also requested a device specifically suitable for paediatric use from the property management company.

We found systems, processes, and policies existed within the practice, however, we found evidence these were ineffective and insufficiently embedded. For example: The practice was in a Primary Care Network (PCN) with 2 other practices. This meant that staff from the other member practices worked at the practice but were employed by other practices in the PCN. However, we found the practice did not have an effective agreement between with the PCN to gain assurances that those staff had been recruited safely, were completing mandatory training, and had scopes of competence to determine the work they could undertake. The practice was unable to demonstrate those staff were receiving clinical supervision and appraisals across the PCN. This posed the risk that those staff may see patients there were not competent to treat, however, we did not find any examples of this. We found a process to record and give leadership and management oversight of risks, but we found limited evidence that risk management processes were used. For example, the risk register contained limited entries and did not include any control mechanisms to reduce or mitigate risks. We also found opportunities to expand the scope of the system existed such as including environmental risks faced by the practice. Due to the limited entries in the risk register we asked whether this document reflected the risks faced by the practice. It was confirmed that it was accurate, but acknowledged there were opportunities to expand the process further to include control measures and other types of risks. We found a system to ensure the practice received medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA). However, we found processes to manage the alerts were not fully effective because we found the practice did not routinely search for patients affected by alerts.

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.