Cherry Tree 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 practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection for this practice 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. However, we found that systems of accountability and governance arrangements were not always clear or effectively implemented. This is explained in more detail in the relevant section of this report. 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.

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 practice 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 the staff we spoke with and received feedback from demonstrated a genuine commitment to provide the best level of care to patients.

The practice was aware of the continued increase to the practice list size and had taken steps to support this in order to ensure the level of care to patients was maintained. For example, through the addition of a female GP to the clinical team, increasing the administrative and reception team, and expansion of the premises.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Staff we spoke with, and received feedback from, were able to give examples of significant events, complaints and learning as a result of these. Information about how to raise a complaint was available on the practice website and in the practice. We found some issues with the complaints process. For example, we noted that the information on the practice website needed to be updated to make clear to patients that complaints could be directed to the practice in writing. We reviewed 2 complaints during our site visit and found that the responses did not include signposting to the Parliamentary and Health Service Ombudsman (PHSO) and the complaints policy contained out of date information. These issues were addressed during our assessment. We also found that there were dual systems in place for logging significant events, and it was not clear who had oversight of this process. We received evidence from the practice following our assessment to demonstrate that improvements had been made to streamline this process, this included a dedicated member of the administrative team leading on the process.

The practice 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 policy in place. All staff knew how to raise concerns within the practice and the practice had established Freedom to Speak up arrangements with a Primary Care Network (PCN) manager for any staff member wishing to raise concerns externally.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Staff we spoke with, and received feedback from, were able to give examples of significant events, complaints and learning as a result of these. Information about how to raise a complaint was available on the practice website and in the practice. We found some issues with the complaints process. For example, we noted that the information on the practice website needed to be updated to make clear to patients that complaints could be directed to the practice in writing. We reviewed 2 complaints during our site visit and found that the responses did not include signposting to the Parliamentary and Health Service Ombudsman (PHSO) and the complaints policy contained out of date information. These issues were addressed during our assessment. We also found that there were dual systems in place for logging significant events, and it was not clear who had oversight of this process. We received evidence from the practice following our assessment to demonstrate that improvements had been made to streamline this process, this included a dedicated member of the administrative team leading on the process.

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

However, we found that systems of accountability and governance arrangements were not always effective. For example, at the time of our site visit there was no dedicated lead for oversight of significant events and complaints. We found that policies and procedures were in place, however these were stored both electronically and in hard copy, and the two versions differed in some cases. The staff files we reviewed during our site visit did not contain all relevant information to evidence that recruitment processes had been followed, and did not contain a clear record of all training undertaken. We discussed this during our assessment and the provider gave their assurances that this would be addressed. We saw evidence following our assessment that the provider had taken steps to transfer onto a computerised compliance and workforce management system which would enable them to record information electronically.

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 took patient confidentiality and information security seriously.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Staff we spoke with, and received feedback from, were able to give examples of significant events, complaints and learning as a result of these. Information about how to raise a complaint was available on the practice website and in the practice. We found some issues with the complaints process. For example, we noted that the information on the practice website needed to be updated to make clear to patients that complaints could be directed to the practice in writing. We reviewed 2 complaints during our site visit and found that the responses did not include signposting to the Parliamentary and Health Service Ombudsman (PHSO) and the complaints policy contained out of date information. These issues were addressed during our assessment. We also found that there were dual systems in place for logging significant events, and it was not clear who had oversight of this process. We received evidence from the practice following our assessment to demonstrate that improvements had been made to streamline this process, this included a dedicated member of the administrative team leading on the process.

The practice 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 contributed to safe, effective practice and research. For example, at the time of our assessment the practice was in the process of planning a patient workshop aimed to improve uptake of childhood immunisations. In addition, the lead GP at the practice was in discussions with NHS West Yorkshire Integrated Care Board (ICB) to initiate a tier 2 weight management service at the practice.