Ringmead Medical Group

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 evidence remotely, spoke with staff, completed remote clinical searches of the practice’s clinical system, and undertook observations while on site. We found the following: We found the practice had a vision for the future, but we received mixed responses from staff about the culture within the practice. We found a lack of effective, embedded or consistently operated governance systems and processes within the practice in both clinical and non-clinical areas. We were not assured that roles and responsibilities were clear or known by all staff. We found there was a lack of effective quality assurance to identify, monitor, manage and continually review risks. We were not assured that leadership and management had an effective system of oversight for all the risks that affected the practice or that appropriate responses occurred when risk were identified. We found there were procedures in place to ensure staff could raise concerns both internally and externally but not all staff could provide clear explanations about how to do this. We found evidence that the practice was open and transparent with the Patient Participation Group (PPG) and had a willingness to work with the PPG to improve services for patients. We also saw evidence the practice took part in and led initiatives with partners and stakeholders to improve the quality of care for patients.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

As part of our evidence collection we asked the provider to share a questionnaire with staff so we could understand the culture within the practice from the perspective of different roles. We received 32 responses which showed some trends due to multiple responses. Examples of our findings were: Many but not all respondents reported they felt supported by line management. Responses were mixed about whether respondents felt concerns raised to management were addressed. We also heard some staff felt responses could be made in a timelier manner. We also received mixed responses about whether staff felt leadership and management were open and transparent and whether staff felt supported by this staff group. We found most respondents felt there were not enough staff employed within the practice. Some respondents reported that communication within the practice was not always effective. There were a mixture of responses where some staff told us they enjoyed working at the practice but others reported they felt there was a blame culture and morale was low. We also heard an example of a member of staff that felt they would not be treated equally if they applied for a different role within the practice. However, during conversations with staff we also heard of 2 specific examples where staff reported the culture was to learn and not blame. The evidence provided by staff indicated the merger had not led to a staff group with a shared vision. Further work was required to ensure organisational culture was positive, compassionate and that staff felt listened and responded to. We were also not assured there was sufficient focus on learning and improvement throughout the practice.

We reviewed the minutes of a partners’ meeting and found these documented a clear vision for what the partners wanted the practice to become in the future and, also what they did not want it to become. Additionally we saw consideration of factors that could impact on achieving this vision. We saw the practice had a detailed long-term plan for how services would be delivered in the future. The plan was aligned to local and national strategic priorities and if achieved would give patients improved access to community primary care services at the practice.

It was explained that the leadership and management were keen to ensure that despite having 5 sites, the merger resulted in a single practice with a consistent identity throughout. Due to the geography of the sites there was natural north and south divide but rather than appointing leaders and managers for each site, a decision was made that the leadership and management team would rotate around all sites to provide visibility, build relationships and work towards embedding the culture and vision for a single practice. Wellbeing was a priority for the practice, and we were given examples of team building events such as a meditation evening and a quiz night, as well as an anonymous survey to request suggestions for improvements to the practice from staff. However, one of the themes within the responses of the staff questionnaires was that although many staff felt supported by their line manager, we found staff did not always feel supported by management. We also found there were mixed responses about whether staff were open and transparent with staff and whether they felt their concerns had been addressed appropriately. We also heard feedback about a blame culture from some staff. Leaders told us the period since the merger had been challenging and staff retention and recruitment had been one of the most significant challenges. It was explained there had been high staff turnover and even instances where staff had been recruited, had started the role and not returned. Resulting in further recruitment being required. We heard the nursing team had seen significant turnover and recruitment very close to the inspection, but leaders were confident they now had a stable management and team in place. These findings suggested there was a poor culture within the practice that was having a detrimental impact on some staff.

Due to the fact the practice had experienced high turnover of staff we asked what action the practice had taken in response to try and identify any themes or patterns and areas which could be improved to increase retention and reduce resignations. We found the practice completed exit interviews with staff where the staff member was willing. The practice also shared analysis they had completed to identify reason for the resignations and any action they could take in response to try and retain staff or make improvements for the future. The most common reasons included health, progression and change, the merger, stress or workload and the locality of the practice. Areas where the practice could make changes had actions assigned, however there were some areas which the practice could not influence. During the assessment we found opportunities to improve many areas of governance within the practice existed because processes were not embedded and had failed to operate consistently throughout the practice. Leaders had either not had effective oversight or had not responded appropriately to make improvements because we found the practices’ own governance had not identified the ineffective processes. We found leaders and management were accepting of our findings but based on the findings, we were not completely assured there was the capacity or capability to ensure that risks would be well managed while improvements were made.

The results of the questionnaire we asked the provider to share with staff showed that most respondents were familiar with how to access the practice Freedom to Speak Up policy. However, from their responses we found not all staff demonstrated a clear understanding of whistleblowing. We found an opportunity to improve knowledge may exist. Responses showed staff were comfortable to raise concerns but felt these were not always addressed or responded to by management in a timely manner. There was also a mixed response about whether leadership and management were open and transparent with staff. We heard several of examples from staff about how friendly and approachable certain teams were when staff needed support. These included the GP partners and nursing team. Overall, we found the practices’ ambition was to create a no blame culture where speaking up and reporting incidents and concerns led to learning and positive change. However, due to the feedback received, our findings were that opportunities existed to embed this vision and ensure all staff were more confident in using the process.

We found the practice had a Freedom to Speak Up policy. This contained limited details about speaking up but signposted to staff to the employee handbook where there was more detailed information about the process. The policy provided details of an external Freedom to Speak Up Guardian and we saw evidence of a poster with these details for use in the practice. Of the 4 complaints we reviewed we found 2 examples where not all the elements of the original complaint were completely addressed, and we also found examples where the complaint had not been acknowledged within the timescales in the practice complaints policy. We also found that learning was not always identified which posed the risk the concern or incident could be repeated in the future. Overall we were not assured the practice had an effective or embedded system which ensured when people that used the service spoke up, they felt their voices were fully heard and positive improvement resulted.

We asked leadership about the high number of significant events categorised as zero tolerance and they explained that since the merger there had been a noticeable increase in the amount of abuse staff at the practice received from patients. The leadership had wanted to recognise this and support staff, therefore they had encouraged staff to record such incidents so the zero tolerance policy could be followed. It was also explained that to support staff to manage such situations, de-escalation training was available. While it was clear the leadership wanted to support staff and had a vision for a fully combined workforce operating as a single practice after the merger, it was acknowledged that the merger process had been challenging and was a significant and relatively recent change. Feedback from staff within the practice indicated opportunities had been missed to fully integrate all staff and to ensure all staff felt valued and of equal status.

Our review of the significant event activity (SEA) log found that 15 of the 29 SEA’s recorded since April 2023 were categorised as zero tolerance incidents. This demonstrated the support the practice was giving to staff while managing challenging situations. It was also evidence that governance processes had identified an issue which could impact on staffs’ health and wellbeing. Leaders explained that staff wellbeing was a priority and provided examples of action they had taken to support staff and make improvements for the workforce. These included further recruitment to support reduction in workloads, creation of a mental health champion and wellbeing lead, promotion of wellbeing and social events for clinical staff and practice meditation sessions.

In relation to the findings of the clinical searches regarding management of patients with long-term conditions, the practice explained several factors had impacted on patient care. These included the patient list increasing as a result of the merger and, a high turnover of staff, particularly in the nursing team. It was also explained that phlebotomy appointments had been booked in clinics but had needed to be cancelled due to staff sickness. We found evidence the practice had recruited to fill the vacancies in the nursing team, and we were recalling patients to book for annual reviews and monitoring tests. Regarding our findings related to governance processes, the practice explained that the prior to the merger happening, there had been a due diligence process to understand the difference between their systems and processes and those of the merging practice. This had identified differences which needed to be aligned. The practice shared examples of the documents used to assess these as evidence of the process that had been undertaken. These included a risk log, actions log and details of the meetings held as part of the merger. Although this documentation demonstrated the risks associated with the merger had been considered, the findings of this assessment were not specific to the merging of the practice and in fact, findings of ineffective or inconsistently applied governance processes were also found at the original practice. Although we received explanations from the practice regarding our concerns, we were not assured that there were clear or effective governance, management or accountability arrangements. We were also not assured staff had clear roles and responsibilities or that systems to identify and manage risk and performance issues were effective.

Our assessment found concerns regarding both clinical and non-clinical governance processes within the practice. In relation to clinical governance, our remote clinical searches found: The practice did not have effective systems to identify, review and monitor patients with long-term conditions including asthma or diabetes. From the sample of medicines reviews our GP Specialist Advisor (SpA) completed we found these did not contain sufficient detail to document what had been reviewed and, the patient was not always involved in the review. Our concerns relating to overall governance were that the practice did not have effective systems or processes in place to ensure the following: That learning was identified from complaints, concerns or significant events and shared appropriately with staff. That recruitment processes in place were effective. That staff training compliance was monitored effectively. That clinical tasks were monitored and actioned. That health and safety risks associated with the premises were effectively monitored, managed, and mitigated. That risks associated with infection prevention and control were monitored and managed effectively. That medicines management processes kept people that used the service safe. Due to these findings we were not assured the practice had effective governance systems and processes in place to identify, review and continually respond to risk or improve processes. Because many of these findings were identified by the assessment, we were also not assured there was an effective system of quality assurance operating within the practice. For the governance processes that were in place, we were not assured they were sufficiently embedded or operating consistently throughout the practice.

The minutes of meetings with the Patient Participation Group (PPG) demonstrated leaders were open and transparent with the group. We saw leaders shared information about staffing, current issues, improvements, and activity that was affecting the practice. For example, the PPG were told the local Member of Parliament had contacted the practice to ask for information due to members of the public contacting them. We spoke with the chair of the PPG and they told us the practice was very honest about the pressure the practice faced and how it was responding. They felt the practice listened to the PPG’s perspective about how services and changes were being received. We were given an example of how the PPG and the practice were working together to create a PPG helpdesk to support patients with information about how to access the practice and services in the community. Of the 35 responses we received from patients during the assessment via our Give Feedback on Care process none related to this quality statement. Neither did existing patient feedback we reviewed dating back to July 2023

During the assessment we spoke with staff, management, and leaders within the practice. They spoke of the PPG helpdesk which assured us that while this was currently in planning and development, it was well known of throughout the practice and was progressing towards becoming operational. This provided evidence that the practice listened to and was committed to working with patients, partners and stakeholders. We found there was a community of veterans within the practice boundary, in part due to being near an army training base. We found the practice was accredited as a veteran friendly practice and could refer patients to specialist veterans mental health services and the veterans trauma network for support meeting physical health needs.

We asked for feedback about the practice from partners, but they had no specific feedback to share about this area.

The practice shared evidence that they had worked with partners including the voluntary sector and the Integrated Care Board (ICB) to identify and support patients that were frail. Several projects had been commissioned and attempted but due to funding and governance processes, these had not been continued. However, 49 of the practice’s frailest and most vulnerable patients had been supported by the project. The support included onward referrals regarding adult social care, benefits, foodbanks, mental health and carer support. The practice also shared the learning they had taken from working in partnership with organisations and stakeholders and were keen to continue doing so. We also heard how the practice supported patients that were homeless by offering a priority access number and priority appointments and by making referrals to other partners to support the persons needs. We found the practice had a dedicated care coordinator to support the care homes registered with the practice. We were told a document had been created to explain all the services available to patients that lived in care homes.

We found examples of initiatives the practice had undertaken to improve the quality of the service for patients. For example, the practice reported they had proactively invited patients that may be at risk of prostate cancer for screening due to a due a fall in diagnoses following the pandemic. Patients were identified via National Institute of Care and Excellence (NICE) guidance and there was a specific focus for patients from black, Asian and minority ethnic backgrounds. The practice shared that to support the transition to carbon net zero they had developed a Champion Team to look at strategies. Examples of initiatives considered included tree planting, switching patients to low carbon inhalers and, reducing the frequency of unnecessary blood tests. We heard that the practice had anticipated some staff would leave after the merger, and there could be several reasons for these decisions. As a result the practice had undertaken significant recruitment campaigns. We found the practice had altered their traditional advertising methods and set up organisational accounts on additional, less traditional websites. The practice reported this had proven to be a successful process when recruiting GPs. The practice explained that while it may have appeared a simple intervention, it had increased the number of job applications. The practice had also transferred to a closer GP vocational training scheme to increase the number of trainees and an additional GP was training to become a clinical supervisor to support this group of staff.

The practice was aware that patients had experienced difficulties when requesting repeat prescriptions. To try and improve the process the practice organised a meeting with all the local community pharmacies and reported meetings continued. The practice explained the outcomes of engaging with the pharmacies from their perspective were enhanced relationships and communication, more efficient and streamlined processes and timelier dispensing of medication. The practice explained they were aware workloads were high following the merger, particularly among certain staff groups. The initial response had been to utilise locums and external support to help with tasks including blood results, patient registrations, and prescriptions. However, this solution was not viable on a long-term basis. Therefore, along with the practice’s Primary Care Network (PCN) research had been completed into the use of automated software to support with these tasks. The practice had self-funded a software package and at the time of the assessment this was about to be launched. The intention was to reduce the burden of these tasks on workloads and improve the experience for patients and the success of the intervention would be continually reviewed based on patient and staff feedback. We also saw evidence the practice completed a demand and capacity optimisation audit to establish the demands on the practice and the impact this could have on capacity and access for patients. The results of the audit included recommendations or suggestions about how the care delivery model could be changed in the practice to ensure it met the needs of patients and was sustainable for staff and the practice. However, opportunities also existed to improve sharing and identification of learning when things went wrong, for example from complaints and significant events and to ensure staff felt it was worthwhile to share concerns.