Bousfield 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

At our last assessment we rated this question as requires improvement. At this assessment the rating has changed to good. We assessed all quality statements within this key question.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture which was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively. Staff spoke of a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. Staff we spoke to and those who completed feedback reported being positive about working at the practice. They described approachable leaders and managers, and a good team of staff who were clear on their function to work in the interests of patients. Clinical staff reported supportive input from all the GPs on site and a constant open-door policy for any patient queries throughout the day.

This was a small practice where the management team included staff who encouraged an open culture at all levels. They understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty. Staff told us leaders in the practice were approachable and responded to any concerns raised. Clinical staff told us how supportive the medical staff were daily. There was evidence of collaboration with other practices in the PCN and engagement to develop primary care services within the local area. Managers had the knowledge and experience to lead effectively and they encouraged improvement. Feedback from staff and people who used the service was positive about leaders.

The practice had an appointed Freedom to Speak Up Guardian within Integrated Care Board (ICB). There was no designated individual within the practice who held this role, but all staff confirmed an open-door policy. Leaders stated that they encouraged staff to speak up, promoted a culture of openness, and had policies and procedures in place to support this. This was evident during the assessment.

The provider valued diversity within the workforce and actively promoted an inclusive and fair culture by supporting equality and diversity among staff. Reasonable adjustments were made to help staff carry out their roles effectively. The provider supported staff with caring responsibilities through flexible working arrangements and adjusted schedules to meet their needs. Staff had completed training in equality, diversity, and inclusion and demonstrated awareness of how to support individuals with protected characteristics, such as age, gender, religion, and disability. There were no concerns reported regarding workforce equality at any level, including recruitment. However, our review of recruitment files identified a need for follow up of declared conditions and review of some missing Human Resources (HR) documentation. The practice had an established equality, diversity, and inclusion policy in place.  

There were effective arrangements in place for governance, management, and accountability. The provider used data to monitor performance and drive improvement. All staff we spoke with understood their individual roles and responsibilities. Managers held meetings with staff with consistent messages communicated across the whole workforce. A regular programme of clinical system searches was carried out by the pharmacy team to identify patient needs and ensure these were addressed. Staff were able to access all necessary policies and procedures and demonstrated an understanding of patient confidentiality and information security. There were systems in place for identifying, managing, and mitigating risks, and a major incident plan was in place. The provider had established governance processes appropriate to the service. During the assessment, we were assured that the provider took all identified issues seriously and acted on them immediately.

The provider demonstrated a clear commitment to collaboration and partnership working to ensure services operated seamlessly for patients. They shared information and learning with partners and engaged in joint initiatives to drive improvement. The provider worked with other practices within their primary care network to deliver extended access services. They also collaborated effectively with external stakeholders, commissioners, and partner agencies to provide and enhance service delivery. The PPG were valued and listened to. When suggestions for improvement were requested such as privacy screens in reception and better car parking these had been or were being implemented

The provider had a focus on continuous learning and improvement across the service. 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 provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.

Leaders told us they maintained strong external relationships that supported improvement and innovation. Action plans were in place to run women’s health clinics and 1 of the nurses had undertaken training in this area. The practice planned to hold a health event during extended hours to educate patients in the management of long-term conditions and about other services available to them such as debt management services, housing issues, and training for patients on how to use the NHS APP.

The practice had also identified that referrals to secondary vascular services were being rejected because there was no ABPI scores. ABPI is an ankle brachial pressure index (ABPI) which is a painless diagnostic test that compares blood pressure in the ankle to blood pressure in the arm, specifically to check for peripheral artery disease (PAD) in the legs. There was nowhere in Liverpool that patients could be referred to for this result and so the practice had trained their nurses to perform it therefore enabling referrals to secondary service for their patients.