Kirby Road 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

The service had improved. There were now clear and effective governance structures in place and comprehensive quality assurance systems. The practice leaders were visible, inclusive, embraced the culture and values of the practice, and had the skills, knowledge, capacity and credibility to lead effectively. There was a focus on staff well-being and development. Leaders were compassionate and took steps to support staff with various needs to carry out their roles well. There was an emphasis on improving the quality of the service and how the practice worked as part of the local health and social care system. Leaders encouraged and supported innovative and creative solutions and improvements, from all staff and people who came into contact with the service.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the vision, values and strategy and their role in achieving them. Staff views were reflected in the planning and delivery of services. Staff consistently spoke about the culture of the team, how they worked well together and how wellbeing was given high priority. This impacted positively on the delivery of patient care.

The vision, values and strategy were developed in collaboration with staff, patients and external partners. Progress against delivery of the strategy was monitored.

Staff told us that leaders at every level, both clinical and managerial, were visible and approachable. The practice had a ‘Suggestions Box’ that staff could post suggestions and comments into, anonymously If they wished. Staff told us they were clear about practice policies and procedures and who they could speak to if they had a question or concern. Staff were positive about the leadership and told us they felt they were supported and listened to. There was compassionate, inclusive and effective leadership at all levels. There was a strong emphasis on the safety and well-being of staff. Staff could access an Employee Assistance Programme, and posters were displayed throughout the practice with information about the support available and how staff could access it. Leaders organised ‘Practice Days’ where staff could discuss concerns and share information in interesting ways alongside well-being activities such as exercise, back care, and being outside. Events such as birthdays and staff achievements were recognised, for example through arranging shared lunches.

Leaders at all levels had the experience, capacity and skills needed to deliver high quality and sustainable care. There was an experienced leadership team in place, who understood both local and national challenges across the health and social care system, and the issues and priorities for the quality and sustainability of the service. Leaders understood the risks and challenges affecting the service and told us about actions they had taken to address these challenges. There were processes to manage performance, and leaders used data to compare the practice’s performance with other similar and local services to monitor and improve the quality of care and service. The practice management team had developed a succession plan.

Staff reported that they felt able to raise concerns without fear of retribution.

The practice had both a Whistleblowing Policy and a Freedom to Speak Up Policy. These included details for the practice’s Freedom to Speak Up Guardian as well as information about organisations staff could contact outside of Kirby Road Surgery if they felt they needed. Freedom to Speak Up Guardians offer support to staff to raise concerns, or speak up, when they feel they cannot in other ways.

There were high levels of satisfaction across all staff, including those with particular protected characteristics under the Equality Act. Staff with physical or mental health needs told us how they were supported and adjustments had been made to help them continue in work. Staff talked positively about their experiences of joining the practice, transitioning to new roles and the ongoing support and development. This positive feedback about the practice’s leadership was reaffirmed by staff in their questionnaires.

There was a strong organisational commitment and effective action to make sure there was equity and inclusion across the workforce. We observed staff included a range of nationalities and were treated fairly and all staff were encouraged and supported in their professional development.

Staff were clear about their roles and responsibilities and who they were accountable to. There are clear and effective governance, management and accountability arrangements. Staff knew where to find policies and guidance.

There were governance structures and systems which were regularly reviewed. For example, practice policies were reviewed and improved or updated in line with the recommendations in them, or when the practice were aware of new guidance or had identified learning, for example from significant events or training. Information, including new or updated policies or clinical guidance, were shared with staff in clinical staff meetings, nurses’ meetings and weekly meetings. The practice had a comprehensive programme of audits, including those already mentioned in this report and audits to monitor the prescribing of medicines used to treat Attention Deficit Hyperactivity Disorder (ADHD). The practice kept an ‘Audit Tracker’ to monitor compliance with the audit programme and to record the most recent findings. Leaders attended weekly Quality Assurance Meetings. In these meetings, leaders discussed: • quality improvement activity, including audits • service improvements, such as in relation to access to appropriate appointments • staff training. Notice boards were in all clinical rooms throughout the practice and contained the same, relevant and up-to-date information. The practice had reviewed their Business Continuity Plan in November 2023. The plan outlined what staff should consider and what the actions to take if there was a major incident or disruption to the service, such as loss of computer or telephone systems; loss of utilities such as gas, electricity and water; fire or flood; pandemic, staff incapacity or terrorist attack. The plan included the details needed to contact relevant services and outlined each person’s responsibilities for cascading information to all members of staff. The practice had ‘buddy’ arrangements with another local practice to support each other if there was a major incident or disruption to the service.

The practice had an active Patient Participation Group (PPG). We spoke with a representative from the PPG who was positive about the working partnerships between the group and the practice. They told us about how they met regularly with leaders and were actively involved in providing and reviewing patient feedback, as well as improvements to the service. They also told us that they were working together with the practice on the recruitment of new members, while aiming for the group’s membership to better reflect the practice’s population. A registration form for joining the PPG, more information about the group, as well as minutes of past PPG minutes were available on the practice website.

Practice leaders reviewed complaints and discussed the learning from them with the practice’s Patient Participation Group. The practice worked with stakeholders to build a shared view of challenges and of the needs of the population.

Feedback from partners was generally positive. We received positive feedback about the way in which the practice leaders engaged with their Integrated Care Board (ICB). Working relations between them were described as proactive, engaged and responsive. ICBs are responsible for planning and delivering local NHS health and care services and work to make improvements and provide better care for people who use services.

The practice worked closely with other local GP practices and initiated developing links with other local services, such as pharmacies and drug and alcohol services. One of the practice’s leaders was a Clinical Director for Chiltern Hills PCN and was a Named GP for Safeguarding for the Bedfordshire, Luton and Milton Keynes Integrated Care Board (ICB).

There was a strong focus on continuous learning and improvement. Leaders were able to describe improvements since the previous inspection. They had taken a structured approach to identify and address issues and to meet priorities and goals. There was a learning culture in the practice which staff and leaders actively participated in, with continuous learning, innovation and improvement supported, at all levels. Staff consistently spoke about the culture of the team, how they worked well together and how wellbeing was given high priority. This impacted positively on the delivery of patient care. The practice had made comprehensive plans for various projects over the next year, including a project that aims to enhance care for young patients with Type 2 Diabetes and another that aimed to further improve the monitoring and review of patients prescribed certain medicines using innovative approaches. Learning was shared effectively and used to make improvements.

There was a quality improvement programme in place. There were well-established systems to learn and reflect from incidents, updates, and staff and patient feedback. The practice carried out clinical audits and other quality improvement activities and was making increased and effective use of PCN-funded resources, such as the clinical pharmacist team who carried out prescribing audits and discussed the results and areas for improvement with the clinical team. The practice were aware of a growing population of older people and that many of these could experience undetected low mood or loneliness. Therefore, in 2022 and 2023 the practice sent Christmas cards to all patients registered with the practice over the age of 80. The practice had received positive feedback about this initiative.