Launceston Close 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

There was a shared vision across the leadership and staff team to provide a good quality service that was responsive to the needs of patients. Staff described an inclusive and positive culture in the main. However, some improvements were required to communications across the staff team at a senior level. Staff understood their roles and responsibilities and the limitations of these and the lines of accountability. Staff told us they felt well supported in their role and there were clear expectations about the training they were required to undertake. However, newer staff were not required to complete mandatory training in an appropriate timescale. The provider told us they intended to change this. Staff told us they felt confident to speak up and that they would be supported if they did and matters would be addressed. Systems were in place for monitoring and managing the performance of staff. Leaders demonstrated that they understood the challenges to quality and sustainability and they took the actions necessary to address these. The practice had a stable, core team of GPs and other clinical staff with clear roles and responsibilities. A review of protected time for clinical staff to undertake their duties was planned. The systems in place for supervision and professional development of the nursing team required formalisation. The provider shared a detailed quality improvement/action plan with us outlining the actions they were intending to take in response to the concerns shared with us and our findings from the assessment.

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.

There was a shared vision across the staff team to provide a good quality service that met the needs of patients. This included an understanding of the needs of the patient population and the challenges. Staff told us in feedback forms that they felt the practice had a clear vision for the future and some staff told us they felt involved in shaping this. Other staff felt they were aware of the vision and values but had not been involved in shaping this. Staff demonstrated an understanding of equality, diversity and human rights, and they prioritised good quality and compassionate care. Equality and diversity issues were identified and equality and diversity was actively promoted. The majority of staff we spoke with or who returned surveys to us told us the culture of the service was positive, open, transparent and supportive. However, a number of staff felt that communication at a senior level could be improved. The provider told us they intended to work with the staff team to improve communication and support a healthy culture.

Regular staff meetings were held and staff were involved in discussions and decisions about the service and service development. The provider was planning to change the structure of staff meetings to include all members of the team in one meeting. This meeting would include sharing the findings from significant events and complaints so that all staff were included in the learning.

The majority of staff we spoke with or received feedback from told us they felt supported by the leadership/management team. Staff reported that managers were visible and approachable. Staff told us the culture of the service was open and the manager had an open-door approach. They said their colleagues were supportive and they were confident and comfortable approaching the management team for any reason. Staff told us teamwork was good and they enjoyed working in the practice. We did however receive some feedback that indicated that communication at the leadership level was not always cohesive or harmonious. The provider told us they intended to work on the communication across and between the staff and leadership team with the introduction of new all staff meetings to include a focus on service improvement, staff inclusion, staff development and team-work.

Leaders were knowledgeable about issues and priorities that could impact the quality of the service. The provider monitored and acted upon data about outcomes for patients. The staff team had expanded in the past 12 months to include staff in new roles such as advanced nurse practitioner (ANP) and pharmacist. Staff in these roles were supervised and supported with professional development. However the systems in place for this were not clearly formalised. The provider had developed and shared with us an action plan to address the concerns raised with us and make improvements to the service.

The majority of staff told us the management team were approachable and supportive and that they were encouraged to raise concerns. They reported a culture of speaking up, where staff felt they could raise concerns and would be supported, without fear of detriment. The provider told us they intended to improve the methods of communication across the staff team to support staff to feel empowered to speak up. Staff knew there was a whistleblowing policy and they told us they would feel confident to speak up if they had any concerns. Staff were confident that if they reported concerns then they would be addressed, and appropriate action would be taken.

There was a designated person who staff knew they had the freedom to speak up to. There were regular opportunities for team meetings and appraisals where staff were encouraged to make suggestions, raise issues or concerns for their personal and professional development or developments to the service. We saw in the management of complaints that people received a sincere and timely apology and were told about any actions planned to prevent a reoccurrence.

Leaders promoted equality, diversity and inclusion. Staff felt leaders would take action to prevent and address bullying and harassment for any staff, including those with protected characteristics under the Equality Act and those from excluded and marginalised groups.

Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. The provider made reasonable adjustments to support staff in their roles and responsibilities. For example, staff with caring responsibilities were actively supported with a flexible approach and changes were made to schedules/rotas to accommodate their needs. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff, training and on going support for staff welfare. Policies and procedures were in place for supporting equality and diversity.

Staff told us they had the opportunity to attend meetings and had protected time for non-direct patient duties for example stock control and training. The provider was scheduled to review the protected time provided and staff were keen to ensure this continued to be provided in line with the requirements of their roles and responsibilities. Staff told us they attended staff meetings and these were held during protected learning time. They told us they found the meetings beneficial, as they allowed them opportunities to discuss issues. The provider was intending to change the structure of meetings to include staff in all roles and to cover additional areas for discussion linked to significant events, complaints and the strategy and vision for the service.

A clear management structure was in place with designated staff members who acted as leads for clinical and non-clinical areas. Staff roles, responsibilities and lines of accountability were clear. New staff were required to undergo an induction. This required review to ensure the induction process is appropriately detailed and includes clear expectations around the requirements for staff training within an appropriate timescale. The provider was actively recruiting to a full time receptionist/administrative post. Structures, processes and systems to support governance and management were set out, understood and effective. Information about risk, performance and outcomes, was monitored and change was discussed and implemented following feedback from people who used the service, staff and relevant stakeholders. The provider listened to our feedback and took action to develop a plan outlining how they intended to make improvements to the service. Information was used effectively to monitor and improve the quality of care and treatment provided. There were effective arrangements for identifying, managing, and mitigating risks. The provider had an overarching risk assessment that identified risks and the measures in place to mitigate these. There were arrangements in place for the availability, integrity and confidentiality of data, records, and data management systems. The provider’s action plan included a review of these linked to patient confidentiality.

The provider used NHS Friends and Family test feedback, the national GP patient survey, compliments, and complaints to assess people’s views or experiences of the service and implement change and improvements in response. Overall, feedback from people who used the service was positive.

Staff and leaders told us they engaged with people, communities and partners and used local networks to identify new or innovative ideas that can lead to improvements in outcomes and experience for people who used the service.

The provider understood their duty to collaborate and work in partnership with other stakeholders. Staff and leaders told us how they worked in partnership with key organisations to support care provision, service development and joined-up care. The practice worked closed with the local Primary Care Network (PCN) and the Integrated Care Board (ICB).

Systems were in place to monitor the quality of the service and make improvements to the experience and outcomes of people who used the service.

There was a focus on continuous learning and improvement across the service. Leaders encouraged staff to speak up with ideas for improvement and innovation. The provider supported on-line and digital transformation as part of service development. The provider worked with stakeholders to improve the experience of the patient population as they worked in partnership to improve services for people within the locality. This included being involved in ways of delivering equity of experience and outcomes and providing high quality care and treatment for people. There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence.

The GP partners had made improvements to the service in relation to the clinical care and treatment and governance since they commenced providing the service. Systems for assessing the quality of the service and outcomes for patients had been developed and were being embedded into practice.