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

We assessed a limited number of quality statements in the key question of well-led. This allowed us to follow up the concerns found at the last assessment where we undertook enforcement activity due to finding a single breach of regulation related to good governance. We also reviewed 2 additional quality statements to gain further insight into the practices’ governance processes. We found improvements had been made since our last assessment and the scores for the quality statements assessed have been combined with scores based on the rating from the last inspection. Our rating for the key question has improved from requires improvement to good and the provider is no longer in breach of the regulation. We found governance systems and processes were improved and were now effective. Where newly introduced, process were becoming embedded in the practice. Governance processes between the practice and the Primary Care Network (PCN) were now clear. Specifically the arrangements and responsibilities regarding staff employed by other practices who also worked at the practice. Processes to manage significant event activity now ensured incidents were investigated so that key learning was identified and shared throughout the practice. The practice now had clear oversight of risks that affected the practice and risk management processes were followed. We also found the practice had a clear vision and strategy for the future which considered the needs of people and communities that used the service. Processes to allow staff to speak up were clear and staff were confident about how to use them.

This service scored 75 (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 were now clear about the governance processes operating throughout the practice. Staff explained their understanding of the processes and were clear of their responsibilities and who they would seek advice or guidance from. Leaders were clear how these systems ensured they could monitor performance and quality within the service and, identify improvements.

There were now clear and effective systems and processes between the practice and the Primary Care Network which ensured staff were recruited safely and in accordance with legislation. Processes ensured staff were qualified for their role and received supervision and development. Responsibility for management of risk was now clear and leadership and management regularly reviewed risks to ensure they had appropriate mitigation. The practice had also improved the governance of significant event activity and medicines safety alerts. Non-medical prescribers that operated under Patient Group Directions were now authorised correctly and the practice had now formally risk assessed a decision regarding the use of emergency medical equipment. The practice had regular meetings with all staff groups where information was communicated and shared within the practice and meeting minutes recorded clearly what had been discussed.

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.

Staff were confident about how they could raise concerns and that they would speak up if they had a concern. Leaders explained clearly how they had developed a culture which made staff feel comfortable to speak up with concerns. Staff confirmed there was an open, transparent, and supportive culture and that leaders were approachable, listened and acted in response to matters raised. Staff were not fearful of any repercussions if they spoke up.

Clear systems and processes existed to encourage staff to speak up. These processes promoted a positive culture around raising concerns and confirmed that staff would be listened to and supported if they spoke up. Policies also encouraged staff to approach external organisations should they not be confident to raise concerns internally. Processes also ensured that when things went wrong, people received an apology and were told about action that would be taken to prevent the situation happening again.

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.

Staff and leaders were now clear about the governance processes operating throughout the practice. Staff explained their understanding of the processes and were clear of their responsibilities and who they seek advice or guidance from. Leaders were clear about how these systems ensured they could monitor performance and quality within the service and, identify improvements.

There were now clear and effective systems and processes between the practice and the Primary Care Network which ensured staff were recruited safely and in accordance with legislation. Processes ensured staff were qualified for their role and received supervision and development. Responsibility for management of risk was now clear and leadership and management regularly reviewed risks to ensure they had appropriate mitigation. The practice had also improved the governance of significant event activity, medicines safety alerts, authorisation of non-medical prescribers operating under Patient Group Directions and had now formally risk assessed a decision regarding emergency medical equipment. The practice had regular meetings with all staff groups where information was communicated and shared within the practice and meeting minutes recorded clearly what had been discussed.

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.