Hope House 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

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

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

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.

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. All staff had contributed to the development of the service’s vision and strategy, which was kept under review.

Staff told us there was a positive team culture and they felt supported by GPs and senior leaders. They told us they were able to contribute to discussions about service improvements, incidents and complaints. All staff we spoke with were proud to work for the service and had a vision to deliver high quality care.

There were established and effective systems to promote a positive culture of learning, collective best service and performance. There was a mission statement developed by staff during annual TARGET training sessions. TARGET is a scheme aimed at improving care by learning new skills, sharing recommendations and incorporates quality improvement activities. The service’s mission statement and values were available and accessible to staff. Positive learning culture was demonstrated through meeting minutes which showed that performance, incidents, feedback and complaints were routinely discussed.

There were effective processes and systems for leaders to share their vision, practical experience and support with colleagues. This was achieved formally through governance meetings and clinical discussions.

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 at the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. We saw the leadership team worked with other GP practices in the primary care network and were engaged in the development of primary care services within the local area.

The service leaders introduced a staff well-being strategy in 2024 in response to staff survey results in 2023. This showed an improvement from 79% in 2023 to 95% in 2024 for 'Staff agree or strongly agree that the service takes positive action on health and well-being'. We saw example of initiatives and wellbeing events which supported the strategy. Leaders supported the continuous professional development of staff. We saw examples of 2 administrative staff who had been supported to complete training for General Practice Assistant roles. In addition, 3 clinical staff had been supported to complete training to enable them non-medical prescriber status.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements in place as well as a whistleblowing policy. The service’s practice manager had completed freedom to speak up training at guardian level and is registered with the national guardian’s office. The local GP federation provided freedom to speak up services for local practices and therefore staff had access to an independent guardian if needed.

The service had oversight of themes and trends which included positive outcomes for people, including staff being treated equally. Where constructive feedback trends were identified, leaders told us there were plans in place to review staff wellbeing and these areas were placed on the service’s improvement plan. The service had set up new ways to support staff. For example, there was a forum where staff could share feedback and concerns informally. Additionally, there were extra communication channels to share updates about services, learn from experiences, and celebrate positive feedback through staff bulletins.

We reviewed the service’s incident management systems and processes, which demonstrated when something went wrong, people received a timely apology and were told about any actions being taken to prevent the same happening again.

There was a zero-tolerance policy in relation to the abuse of staff with mechanisms in place to protect people and minimise the likelihood of reoccurrence.

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. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued. For example, there were reasonable adjustments in place to support the risks posed to the health and safety for workplace display screen equipment, working whilst pregnant and movement and handling. There were flexible working arrangements for multiple reasons including childcare/personal health or other caring responsibilities/religious practices. The service had provision for sit-to-stand desks for musculoskeletal conditions, specialist seating/computer equipment and dedicated area for prayer space.

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 supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders 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. Leaders held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Leaders clearly recorded any actions arising from these meetings and ensured they shared these with staff.

The service had a business continuity plan in place which gave guidance to staff for the preparation of major incidents. Staff were able to demonstrate how to access service policies and procedures and gave examples of how working arrangements had been adjusted due to past risks or incidents.

The service worked to improve sustainability including through wider recycling, composting appropriate waste in the 'Garden of Hope', introducing cycle to work scheme, switched all paper material to recyclable, fitted solar panels and introduced ‘green’ prescribing. The service had been recognised with ‘Bronze’ accreditation to the Royal College of Physicians (RCGP) ‘green tool kit’, aiming to address the impact of climate change in general practice.

Information was stored securely in line with digital security standards with relevant information available in line with privacy, consent notices and general data protection regulations. This included how people’s data was used, choices regarding consent and how to protect online data through notices within the service, registration forms or online via the service’s website.

However, although the service had oversight of the health and safety risks posed to people in relation to the premises, the service’s governance systems had not identified and always ensured effective control measures were in place. In particular, reducing the risks related to cleaning equipment for infection prevention and control purposes and initial awareness and controls for managing and controlling the risk of legionella bacteria. The service immediately sought assurances from external contractors to minimise the risks posed to people.

The service understood their duty to collaborate and work in partnership, to ensure services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff had made adjustments to improve coordination of their service with community healthcare services, centred on the care of those at higher risk of hospital admission. The service utilised additional support roles via the primary care network (PCN) to provide extra support for a variety of people with more complex needs such as those who were vulnerable and assessed as frail. Community providers shared positive feedback about their experience working with the service, such as community mental health and nursing teams. They highlighted a collaborative approach to monitoring and delivering care tailored to people's needs. This included support for individuals with poor mental health and those receiving end-of-life care.

The service worked with healthcare partners in the development and review of locally agreed clinical pathways. Feedback on outcomes following referrals were shared with both the service and the relevant healthcare providers.

The service carried out a project with support from a national charity, Trauma Breakthrough. This helped provide support and referral links to people using the service for adult survivors of trauma and abuse. This partnership enabled people to access training in how to provide effective support for those struggling with their mental health following trauma or abuse.

The service had a strong focus 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 contributed to safe, effective practice and research.

The service was listed as a research practice and had 6 members of staff who hold ‘Good Clinical Practice’ certification. The GCP certification is issued once a person has completed a GCP training course from a recognised provider and is essential for anyone involved in clinical research, especially Clinical Trials of Investigational Medicinal Products (CTIMPs), to ensure participant safety and data reliability, and is a legal requirement for CTIMPs in the UK. The service was a member of the Oxford Royal College of General Practitioners research and surveillance centre and contributed serology and virology health-related data which contributed to monitoring communicable disease and vaccine efficacy across England. The service used this research data to ensure vaccination schedules were evidence-based and person-centred, whilst contributing to future treatment development. This proactive approach meant people received vaccines which supported disease prevention across the local community.

Other examples of research studies the service had provided learning and contributed to include the use of rapid respiratory microbiological point-of-care testing and whether this reduced same-day antibiotic prescribing for people who presented with respiratory tract infections. Participants were randomised to either receive in-house testing (for full panel of viral bacterial infections) or not. This benefited the participants who were tested as it ensured they only received antibiotics if needed whilst also receiving the correct antibiotics first time, speeding up their recovery and improving antibiotic stewardship. Those who were tested and found to have a viral infection re-presented less often than those who were not tested. This will benefit future people following the research study by reducing further unnecessary presentations to health services.

The service was part of a randomised double-blind research study which investigated whether prescribing 10 weeks of amitriptyline medicines (medicines used to treat depression and nerve pain) at diagnosis of shingles prevented post-herpetic neuralgia (a nerve condition that causes long-lasting, painful nerve damage following a shingles infection) as opposed to nationally recognised anti-viral treatments only. This benefited the service’s patients by enabling them to receive early appropriate pain relief (depending on randomisation) and prevented the development of post-herpetic neuralgia. It also increased awareness of post-herpetic neuralgia amongst the service’s clinicians to ensure it is appropriately assessed and managed, whilst contributing to new evidence-based treatment guidelines.

Two members of staff part of the ‘Optimal Testing Study’ work package as part of the NHS Health Research Authority in April 2025. This project reviewed health resources and service websites, enabling them to be refined and reviewed as part of the research study. The aim of the project was to enable more appropriate use of NHS resources for monitoring long-term conditions and make the information around these tests and results more accessible to people and to manage their care more effectively, which at the time of assessment was still ongoing.

The service was also listed as a training practice which helped support GP registrars. There were 3 GP trainers assigned as mentors, and the service provided tutorial support for medical students. This helped to improve the local health economy by developing clinicians with ambitions to retain staff for the long-term resiliency planning.