The Limes Medical Centre

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

At the last inspection we found the practice did not have embedded governance systems, there was a lack of leadership and oversight, the culture did not effectively support high quality sustainable care and there was no evidence of systems and processes for learning, continuous improvement and innovation. At this assessment, we found further concerns in the leadership and culture of the practice and found the provider had not taken action to address areas of governance, management and accountability. We found there were no clear systems in place to ensure staff had the skills and knowledge and support so that people had safe care and treatment. We found staff morale was very low with a number of staff reporting there was a continued lack of communication. Some staff reported being unable to approach leaders for guidance and support. At the time of the assessment, we found the practice manager was not in work; however, staff were being supported 1 day per week by an interim manager; however, we found this was not sufficient and areas within the practice was not being fully managed. We found that there was a lack of leadership in place to ensure there was adequate oversight to manage risk, issues and performance. There were no succession plans in place and we did not have assurances that concerns identified would be addressed or sustained.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the last inspection in April 2022, we found that the practice culture did not always effectively support high quality sustainable care. At this assessment we found that culture and communication had deteriorated further, and staff reported a lack of support and being unable to share concerns without fear of retribution. We found several staff upset on the day we visited. They shared their concerns on how they were being excluded, how communication was poor and concern around the management of patients which was impacting on them being able to do their job appropriately. Staff told us leaders were aware of the concerns, however this had not been addressed. The practice leaders were unable to demonstrate they had considered the impact on their staff and how they had implemented supportive measures to ensure the health and wellbeing of all staff. We found there was a closed culture and learning was not shared with staff to make improvements and mitigate future risks. There was 1 practice meeting held in 6 months which had not been attended by some staff. Staff told us that some meetings attended, resulted in a blame culture, leaving staff upset and undervalued. We found significant concerns in the lack of openness and poor communication amongst the workforce, leading to inconsistent processes and confusion amongst staff which was continuing to impact on staff morale and service delivery. The practice’s aims were to have a commitment to provide effective, individualised quality healthcare to its patient group and aimed to achieve this through the collaborative input of all team members, who’s evidence base, knowledge, skills and attitudes establish and maintain this standard. The GP partners were unable to demonstrate these values were at the forefront of their leadership of the practice and feedback from a range of staff demonstrated a lack of understanding of the challenges they were facing and limited engagement with the leaders.

We found systems to ensure compliance with the requirements of the duty of candour and processes in place for communication and shared learning was ineffective. There was a whistleblowing policy in place but no named freedom to speak up guardian outside of the practice. Staff had not completed mandatory training which included equality and diversity.

The Limes Medical Centre was registered as a three-member partnership practice, however one of the partners had left the practice 2 years prior and they had not applied to remove them from the CQC registration. We found concerns which related to the effectiveness of patients' care and treatment due to the leadership not being inclusive, staff having no direction or support and inconsistencies in how leaders operated and communicated. Staff described some of the practice team as supportive, however we were told that some leaders were unapproachable, and relationships had broken down. At times staff felt they had no one to turn to if they had a concern and when these had been raised there was no review to address this. We found leaders did not have the appropriate oversight and supervision to ensure staff were carrying out their roles effectively. We were unable to gain assurances that the leaders understood the challenges to quality and sustainability to ensure there was capable and effective leadership.

We were unable to gain assurances from the leadership team that there were plans in place for the development of staff and that there were processes in place that were consistently being followed. For example, we found a number of pathways implemented that were not being followed and staff told us they were held to account for processes that was not in place.

There was no Freedom to Speak Up Guardian outside of the practice. Feedback from the majority of staff working in the practice told us that staff concerns were dismissed from leaders or concerns raised created a fear of retribution. For example, meetings attended by some staff left them feeling upset and staff were not confident that their voices would be heard. Specific tasks requested of staff did not always support them to feel valued in their role. For example, staff told us they were disciplined for not following processes they were unaware of. Overall, we found that leaders did not actively promote staff empowerment to drive improvement or encourage staff to raise concerns and promote the value of doing so.

We did not see evidence or process to support staff in line with a named freedom to speak up guardian outside of the practice and that which was in line with best practice.

We were not assured of the emphasis on the safety and well-being of staff. We were told that staff had been working for months without adequate lighting and on the day of our assessment there was no running hot water. Staff told us that risk assessments or reasonable adjustments had not been carried out for staff who required it; resulting in some instances where staff purchased their own equipment. There was poor communication and an avoidance to engage with departments within the practice. Staff were working in silos with limited engagement between leaders and staff. At the last inspection we spoke with leaders about the culture of the practice and were told there were plans to meet as a team and address areas for improvement. However, feedback did not provide us with assurances that those staff with protected equality characteristics and those who are excluded or marginalised, or who may be least heard within their service would be supported adequately

We found limited processes in place to review and improve the culture of the practice in relation to equality, diversity and inclusion. There were limited processes to support staff to feel empowered or confident that their concerns and ideas resulted in positive change to shape services and create a more equitable and inclusive organisation.

Staff told us that practice policies were accessible, however roles and responsibilities were not clear, and staff felt there were not supported by the leadership team. We found there was no clear oversight for the management of risk. For example: we found that areas within health and safety and fire safety had lapsed. We were not assured that newly appointed staff had completed an induction and training and had opportunities through training and development to improve their job skills. We saw no evidence of regular management meetings to review sustainability and ensure there was enough staff in place. We did not feel assured there were contingency plans for the needs of the service. For example, at the time of our assessment both GP partners were on annual leave, however there appeared a lack of communication with other clinicians of the intended cover arrangements during this period. Staff feedback highlighted how patients were booked inappropriately with staff who did not have the necessary skills to be able to meet the patients' needs. This had been reported to the leadership team; however, no action had been taken, resulting in other clinicians implementing their own processes.

We found processes required strengthening to ensure risk monitoring was effective. We were unable to gain assurances that risk assessments had been completed for health and safety. There was an ineffective process to identify, understand, monitor and address current and future risks including risks to patient safety. This included the actioning of safety alerts and ensuring learning was shared to mitigate future risk and identify trends. The leadership team told us about their processes in place, however some staff were not aware of these processes or told us that some clinicians did not always work within the processes set out. We found that quality outcomes framework (QoF) performance was monitored but this was not always effective to ensure patients were receiving the appropriate care and in a timely way. On reviewing a random sample of patients on high-risk medicines or with long term conditions we found they had not received the appropriate or timely reviews.

There had been no active patient participation group (PPG) since 2019, however the management team told us that they were in the process of organising this and we saw evidence that contact had been made with previous members.

We found practice meetings were not being held regularly and there had been 1 practice meeting in the last 6 months. Staff reported a lack of support and poor communication from the leadership team.

The GP partners told us they were working with the primary care network and stakeholders to ensure that resources were planned and there was regular collaboration and partnership working to meet the needs of the patients.

We found some evidence to demonstrate that the practice had processes in place for partnership and community engagement. For example, we received evidence to demonstrate that safeguarding meetings were held, however we were unable to gain assurances that these meetings and the outcomes were being shared with health visitors or local community services. We were told that multi-disciplinary meetings were being held, but no evidence was provided to demonstrate that regular meetings were held with other community teams to ensure patients receive the appropriate support, care and treatment.

Feedback from staff highlighted they were unable to develop their roles due to time constraints and not being given protected time to do their learning updates. Staff informed us they were expected to do updates in their own time. There had been 1 practice meeting held in the last 6 months. Staff told us that learning from complaints and significant events outside of this meeting was not shared.

The practice leaders were unable to demonstrate they had effective systems in place for learning and development. We identified gaps in staff training in a number of areas that the practice deemed as mandatory. We found there was limited opportunities for staff development, with staff not been given time to complete training during working hours. There was planned audit activity in line with quality outcomes requirements which was undertaken by the clinical pharmacists, however there was limited oversight to ensure improvements were implemented and maintained and the safety of patients was regularly reviewed through monitoring and learning and that this was actively shared with the practice team to mitigate risks.