Hodford 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

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 under the previous provider, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 68 (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 did not have a formal and clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We were not provided with the practice’s mission statement and values and staff we spoke with during our assessment could not explain the practice’s mission statement and values. However, staff were able to identify challenges to the practice and were confident in raising issues when necessary. Staff explained how they had opportunities to provide their input when changes were made.

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.

Leaders maintained an open-door policy and staff told us leaders in the practice were approachable and responded to any concerns raised. Leaders made reasonable adjustments and supported staff for further development and training opportunities.

Leaders regularly engaged with other practices 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 practice had a Freedom to Speak up Guardian and an established whistleblowing policy which detailed external Freedom to Speak up arrangements. Staff were aware of how to access policies and raise concerns where necessary.

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 in place and were accessible by staff. All staff had completed their equality and diversity training, and staff told us they worked well together and supported each other. Adjustments had been made to ensure all staff were valued, with adjustments made to support disabled staff including flexible working arrangements to accommodate conditions.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders and managers supported staff, and staff we spoke with were clear on their individual roles and responsibilities. Although the practice had assurances and governance policies in place, this was not always followed and we found improvements in systems and processes were required. We reviewed a sample of staff files during our on-site assessment and found appraisals and performance reviews had not been completed for most staff. The practice had a policy for clinical supervision, but we did not see any evidence of formal clinical supervision being undertaken.

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 could access all required policies and procedures. Staff had completed information governance training and were able to explain ways to maintain patient confidentiality.

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 practices within their primary care network to offer extended access. The practice did not have an active Patient Participation Group (PPG). We spoke with previous members of the PPG and have been told that the practice had been actively trying to promote PPG participation.

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 practice implemented clinical audits and quality improvement processes to improve quality of service. For example, where issues were identified around booking physician associate (PA) appointments, the practice improved patient communication and introduced guidance for staff to allow more appropriate bookings. Additionally, the practice introduced a structured long-term condition (LTC) pathway, involving staff through ongoing monitoring and regular reviews, improving LTC management and staff confidence.