Albany 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 looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

During a recent team day, all staff had contributed to the development of the service’s vision and strategy, which was kept under regular review. The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Staff told us leaders were visible, knowledgeable and supportive. There was a culture of continuous improvement and staff were given time and resources to try new ideas and ways of working such as introducing a AI powered software application called “BetterLetter”, this is used to automate the processing, coding and filing of clinical documents.

The service had inclusive leaders at all levels who 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. They did so with integrity, openness and honesty.

Staff told us leaders in the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service.

There was a clear staffing structure, and staff understood their roles and responsibilities. They had access to line managers and senior leaders and felt able to seek advice and guidance when needed.

We saw the leadership team worked with other GP services in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a freedom to speak up policy which clearly laid out the process of raising concerns, including the name and contact details of the service’s freedom to speak up guardian (FTSUG - a person who supports workers to speak upwhen they feel that they are unable to do so by other routes).

Staff told us they were supported and encouraged to raise any concerns or issues and felt they were able to do this without the fear of blame or criticism.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were available, and staff had received up-to-date equality and diversity training.

Staff gave examples of how the service made reasonable adjustments to support their family circumstances and health needs, such as flexibility around their childcare and other caring responsibilities, as well as working from home with equipment provided by the service and appropriate confidentiality arrangements adhered to.

Leaders actively promoted staff wellbeing through social events, which staff said helped to foster positive working relationships, encourage inclusivity, and contribute to a supportive workplace culture.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders and line 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. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. staff. Staff took people’s confidentiality and information security seriously.

The service held regular meetings, these included: multi-disciplinary, clinical, quality, partner and Patient Participation Group (PPG) meetings. There was a set agenda and staff who could not attend knew where to find the minutes.

Leaders had effective systems and processes to ensure mandatory checks were carried out within the relevant timescales. For example, health and safety risk assessments and maintenance of equipment, such as fire extinguisher checks and calibration of clinical equipment.

Leaders worked together to maintain the running of the service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other services within their local primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service was a training practice for doctors training to become GPs. To enable the provider to be a training practice they must meet specific criteria including having adequate facilities and a supportive learning environment which Albany Surgery does.

The provider had a clear plan for quality improvement to ensure continuous development of the service such as using feedback from people using the service, complaints and compliments, team meetings and significant events. Progress was monitored through management oversight, audits and ongoing feedback. All staff were encouraged to put forward and test out new ways of working to meet the needs of the practice population.