Southway 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 assessed 4 quality statements from this key question. We found leaders could not demonstrate they had the capacity and skills to deliver high quality sustainable care, the overall governance arrangements were ineffective, and the practice did not have clear and effective processes for managing risks, issues and performance. As a result, we have identified a breach of Regulation 17: Good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Most staff feedback regarding the culture of the practice was positive. Staff were unclear if the practice had a clear vision for the future but all staff recognised the need for another permanent GP.

The practice had a business development plan and succession plan in place; however, these had only been completed in July 2024, at the time of the assessment. The business development plan highlighted strategic goals for the forthcoming 3-year period including having aspirations to become a training practice in 2026 and to further develop leadership roles within the practice. This was supported by an action plan and timeline to achieve these goals.

Staff described the practice team as supportive, however, some staff told us they did not feel leaders listened to their views and felt leaders were not always visible or approachable. Some staff told us they felt communication needed to be improved to ensure all staff were aware of updates and learning across the practice.

Whilst we were aware of the difficulties the practice faced with ongoing staffing challenges. Leaders could not demonstrate they fully understood the challenges at the practice and therefore had not always identified actions to address these. For example, we highlighted a number of concerns throughout the assessment that had not been identified or mitigated by the practice. This included areas relating to medicines management, safeguarding and formal supervision for a non-medical prescriber. The practice had not held whole team meetings which meant staff did not often have the opportunity to raise concerns or items to discuss, be involved in strategic planning or receive regular updates.

Most staff within the practice were unclear on the arrangements to raise concerns. This included the role and importance of ‘Freedom to Speak Up’. Some staff told us they were unaware of how and who to raise external concerns to.

The practice had a first version Freedom to Speak Up policy in place which had been created in November 2023, however, it had not been approved by another member of staff. We found a Freedom to Speak Up Guardian had been identified at another local practice for staff to access, however, these details were not easily found within the policy and staff were not aware of the guardian.

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 and staff told us about the challenges the practice had experienced over the last 12 months and recognised the need to strengthen the management structure and overall governance framework. Staff informed us that up until the assessment in July 2024, there had been a lack of appraisals, supervision and there was a lack of communication of updates, including outcomes and learning from significant events.

Most of the practice policies, guidance and business development plan submitted to us in evidence were first version documents, created in July 2024, and had not been approved by a second reviewer. This meant documents were not yet embedded into the practice and errors in the documents had not been identified. For example, we found errors in the safeguarding policy relating to contact details and who the appropriate safeguarding persons were in the practice. There was a lack of oversight of systems and processes to monitor the quality of care relating to high-risk medicines management, long term conditions and the systems in place to ensure staff had the appropriate skills and knowledge was ineffective. The systems and processes to manage significant events, complaints and health and safety risks was not effective, and the practice did not always respond to identified risks in order to mitigate them. For example, we identified outstanding actions from previous health and safety risk assessments which had not been addressed.

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.