Grove Park 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 assessed all the quality statements from this key question. Our rating for this key question is good. We found the practice was providing a well-led service overall. All staff we spoke to felt supported and were dedicated to delivering the vision and strategy of the practice. However, some improvements were needed in relation to how the practice engaged with all people using the service.

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.

Staff we spoke to understood the vision and strategy of the practice and their role in achieving them. Leaders demonstrated that they listened to staff and that there was a learning culture. However, not all people who used the service told us they were sufficiently informed and listened to in relation to decisions about the direction of travel the practice had taken since the merger.

There was a practice mission statement which was readily available to staff. The learning culture was demonstrated through meeting minutes which showed that performance, incidents, patient feedback and complaints were routinely discussed. The practice provided evidence of the steps they were taking to engage better with all people using the service.

Staff told us they were well supported by leaders who were visible and approachable. Leaders were knowledgeable and explained the challenges of delivering good quality care and were working towards improvements.

Leaders were visible through attendance at team meetings, multidisciplinary team meetings, Primary Care Network (PPN) meetings and Patient Participation Group (PPG) meetings.

Staff told us they were supported and encouraged to raise concerns, and they were confident that leaders would take them seriously.

The practice had speaking up policies and staff had undertaken training on being open and Duty of Candour. Policies were available to all staff on the computer shared drive. When we reviewed the speaking up policy, we found that a senior member of staff was not listed as the designated contact for raising concerns and the staff member listed also served as the Freedom to Speak Up Guardian. After we made them aware, the provider amended the policy and assigned the role to an external, independent individual outside the practice in accordance with best practice guidance.

Staff we spoke to told us they had not experienced discrimination or discriminatory behaviour whilst working at the practice. They told us that leaders treated them as equals. Staff told us they had undertaken training in equality and diversity and that HR policies supported this.

There was evidence from policies that leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. There was no evidence of discrimination built into any of the policies we reviewed. Staff had undertaken training modules in equality, diversity and human rights. A staff survey had been conducted which demonstrated the practice had collected, analysed and responded to staff feedback which was generally positive.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff told us they were provided with sufficient training and professional development opportunities.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures, and the policies we reviewed were accurate and current. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously. There was a business continuity plan which was accessible to staff.

Feedback from people who used the service including from surveys and direct communication with people was very mixed. We met with two representatives of the reconstituted Patient Participation Group (PPG) who told us they were committed to improving services for people through collaboration with the practice. The PPG had started to meet with the provider on a regular basis. They told us that they were currently involved in the co-design of an action plan based on people’s feedback and designing a survey to send out to all people using the service.

Staff and leaders told us they had strong relationships with healthcare professionals within the local community to support care provision and joined-up care. Leaders showed us evidence of numerous communications with partner organisations including the Primary Care Network (PCN) and the Integrated Care Board (ICB).

Visiting healthcare professionals in the service did not raise any issues about how the service interacted with them.

The practice had a new PPG which was being developed. People could also join a wider PCN PPG.

Staff told us they really enjoyed working at the service and several staff had worked there for a number of years. They had been encouraged to develop their skills set to enable them to take on new roles and responsibilities. Learning needs were discussed in team meetings and individual needs were identified in annual appraisals which staff found helpful. Leaders told us they wanted to support and encourage staff to develop within the service. Leaders had a good understanding of the practice’s performance.

The practice had systems in place to learn and improve. Team meetings were used as a tool to share learning, audits were carried out to improve outcomes for people and systems were in place to monitor and improve performance. The practice understood the challenges they faced and had put in place mitigations.