Lighthouse Group Practice

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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 and inspected against one quality statement; Governance, management and sustainability. During our assessment of this key question, we found the practice had failed to establish clear and effective governance arrangements in relation to staffing files and recruitment. Systems were not embedded to ensure records were maintained in line with Schedule 3 requirements of the Health and Social Care Act 2008. The above evidence resulted in a breach of regulation 17 Good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Although there were policies in place to support the recruitment and development of staff, these were not always followed by leaders and they were not always aware of the shortfalls relating to staff records. They had become aware of the shortfalls that incurred following the incident of recruiting staff without DBS checks and had taken learning. Leaders told us that practice policies had been reviewed and more effective oversight of recruitment and the ongoing management of staffing records would be held by the new HR manager. The HR manager planned to review and update all staffing records that did not meet the Schedule 3 requirements of the Health & Social Care Act 2008. This individual would be supported during the implementation of the new practice electronic systems and performance would be monitored through senior leadership meetings on a routine basis. Staff told us the practice had carried out annual staff feedback and were in the process of reviewing and identifying trends to implement service improvements at the time of assessment. Staff were aware of the practice Employee Assistance Program (EAP) to support wellbeing. Staff were able to raise concerns, including identifying the freedom to speak up guardian. Leaders were made aware of their responsibilities for raising and submitting statutory notifications to relevant organisations such as CQC)or National Health Service England (NHSE) after prompting, following the DBS recruitment incident in May 2024. Oversight of patient feedback was managed effectively. Feedback and views on treatment and care were obtained through surveys and ‘Friends and Family Test feedback’. Leaders were able to demonstrate themes that particularly reflected on staffing which had an impact on the way the practice managed rotas and cover arrangements. Staff were able to describe actions that had been taken in response to service user feedback such as a change to planned staffing provision to meet people's needs.

Although there were systems and processes in place to identify risk; these had not always been effective in identifying shortfalls in relation to staff records. The practice had not identified recruitment and HR records were not always kept in line with practice policy despite the previous recognised lack of DBS checks for some staff members in May 2024. This included the effective oversight of recruitment of staff at Primary Care Network (PCN) service level. The practice had also not identified that staff competency and training records were not always available to support the practice in monitoring compliance with their staffing policies. We identified that clinical supervisions were not always formally recorded in line with practice policy. Staff training that was deemed mandatory by the practice had not always been completed and systems were not always effective to monitor compliance to training completion. The practice was in the process of implementing a new staff training system at the time of assessment, in which oversight of staff performance planned to be monitored by the newly recruited HR manager. Although a system was in place to monitor staff training compliance, we had to prompt the service to review these records. Staff deployment was managed effectively. We found action had been taken in response to high demand for appointment access through effective management of staff rotas. The practice had a succession plan in place to replace those who were likely to retire and planned to support staff to encourage leadership in key areas in the practice. Patient data was stored securely in line with digital security standards with relevant information made available to access in line with privacy, consent notices and general data protection regulations (GDPR). Information was available for patients on how their data was used, choices regarding consent and how to protect their online data through notices, registration forms or online via the practice website.

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.