Abbamoor Surgery

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 reviewed 7 quality statements in the Well led key question – 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 and learning, improvement and innovation. During the assessment we reviewed policies, spoke with staff, and undertook inspection activities on site. We found effective governance and risk management systems and processes. We saw information was used effectively to monitor and improve the quality of care. Staff reported that leaders were visible and approachable. There were named leads in place for key areas and staff were clear about their roles and responsibilities. Leaders had a deep understanding of local population issues, challenges and priorities for their service, and beyond.

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.

The practice had a clear vision and credible strategy to provide high quality sustainable care. Staff knew and understood the vision, values and strategy and their role in achieving them. The practice encouraged the quality of candour. The GP partners promoted an open-door policy to all staff. All staff we spoke with reported the leaders and the practice management team were visible and approachable. We reviewed copies of a staff survey completed by five members of practice staff. Overall feedback was positive, and staff felt valued. Staff commented on the need to recruit more reception staff to help cope with growth of the practice and increased demand.

We saw a detailed business plan, with clear strategies and objectives for the future. There were systems to ensure compliance with the requirements of the duty of candour.

We spoke with a range of staff members remotely and onsite and received 6 staff CQC questionnaires. Information provided in the questionnaires showed staff felt supported by leaders and managers. Staff provided positive feedback about working at the practice which indicated that there was a good working culture. Policies and procedures were maintained in an organised way and easily accessible to staff. The practice offered apologies to people, lessons were learnt from complaints and action was taken as a result to improve the quality of care. There was structure in place in terms of meetings and sharing of learning with staff. Learning was shared effectively and used to make improvements. Leaders were able to show us they understood some of the challenges they faced.

The practice had policies and procedures in place to support the learning culture. The practice offered apologies to people, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care.

The practice staff had access to a Freedom to Speak Up Guardian. Staff told us they now felt the leaders were approachable and felt comfortable to speak up.

The practice had a Whistleblowing Policy and Procedure last reviewed in February 2024.

Staff felt that leaders took workforce wellbeing seriously. Staff described the practice as a good place to work with friendly and supportive staff. Staff we spoke with told us there was an open culture and leaders were approachable. Staff we spoke with understood the needs of different cultures and groups of people.

The practice’s equality and diversity policy included that leaders valued the rich diversity, skills and abilities that people from differing backgrounds and experiences bring to the workplace. During our review of staff training, we found that four members of staff had not completed equality and diversity training. Immediately following our assessment, the practice sent us evidence of completed equality and diversity training for those staff.

Staff told us they had complete access to all the practice policies and procedures, which were reviewed on a regular basis. The GP partner was the governance lead. Leaders demonstrated they understood some of the challenges they faced. They had successfully recruited a nurse and told us they were looking to recruit another salaried GP because the practice had taken on another 800 patients over the last year.

The practice had clear processes and systems that worked effectively. Governance structures and systems were reviewed regularly. Practice team meetings were held monthly where they regularly had discussions on learning and staff could discuss any concerns they had. Staff were aware of the process to raise significant events and encouraged to do so. The practice had processes for managing risks, issues and performance. This included risk assessments, learning from safety alerts and significant events. However, although there was a process for monitoring staff training, we found managers had not identified gaps in staff recruitment checks. Following our inspection, staff sent us evidence of completed recruitment checks and mandatory training completed. We saw examples of quality improvement activity completed within the last 12 months. Clinical audits had a positive impact on quality, and there was evidence of an audit programme for continuous improvement. People felt that the staff were caring and gave advice and signposted people to further support. The practice had a business continuity plan.

Leaders informed us they regularly met with other practices within the Primary Care Network (PCN), and they had good engagement with the Integrated Care Boards (ICB). The practice had an active Patient Participation Group (PPG). We received mixed feedback from the participation group. People told us that the practice could improve how managers engage with the PPG and listen to suggestions and feedback. It was not clear from PPG meeting minutes how often practice leaders attended the PPG meetings in person and people reported inconsistencies in managers following up actions agreed at PPG meetings. However, there was positive feedback that patients felt that their care needs were routinely reviewed, and staff and patients were supported to manage their health in a way that made sense to them.

The leaders told us they collaborated with stakeholders and had active intensive case management meetings engaging with District nursing, Care Agencies, Mental Health, Care Navigators, Palliative Care. In addition, they had regular meetings with Health Visitors. The practice had a Social Prescriber, a Health & Well Being Coach, a Mental Health Practitioner, a physiotherapist and a dietician at the practice, who were employed through the PCN.

The PCN clinical pharmacist lead gave us positive feedback about the GP Partner and his commitment to putting patients first. We had no feedback from any other external partners.

Leaders told us they had worked in partnership with Havering North PCN to address resource-intensive challenges in chronic disease management. The GP Partner had created a health intelligence platform to improve management of patients with chronic diseases and improve treatment and outcomes for their patient population. The platform was successfully piloted with partners in the Havering North PCN between October 2022 and September 2023 and outcomes showed a significant improvement in chronic disease management.

Staff told us learning was shared through meetings and regular discussions to make improvements. Performance data was reviewed at governance meetings and practice meetings and actions agreed. Audits and quality improvement activity formed a key part of the practice learning and improvement. The practice held significant event meetings to share learning across staff roles reflecting that there are often multiple causes to these. Patients were encouraged to feedback via the Friends and Family Test survey on the practice website which is reviewed at practice team meetings. Staff told us about changes made after feedback from the PPG.

The GP Partner had oversight for processes and systems, they had regular communication with staff. Leaders ensured staff received ongoing support and training. The practice had a programme of quality improvement.