Waterbeach 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

This means we looked for evidence the practice was led effectively and in a way that was inclusive, supported improvement and innovation and made sure people received care that was safe and effective.

At our last assessment with the previous provider, we rated this key question requires improvement. At this assessment we have rated this key question 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. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. During our assessment we found areas of risk that the practice safety and risk processes had not identified. Leaders were keen to promote a culture of continuous improvement and review their processes.

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 established and embedded a shared vision, strategy and culture which reflected the principles of transparency, equality, diversity, inclusion and respect for human rights. Staff demonstrated a clear understanding of the practice's values and how these shaped the delivery of care. Staff told us that the leadership team actively encouraged openness and maintained a welcoming and inclusive working environment.

The practice had identified future challenges associated with local population growth and was working collaboratively with partner agencies to plan for increasing demand. The practices’ priorities were clearly documented through their business plan. All staff had contributed to the development of the practice vision and strategy, which was kept under review.

The leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area. Staff spoke positively about the culture within the practice, and this was aligned with what we observed throughout the assessment.

Practice leaders at all levels 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 described leaders as accessible and supportive, and said they responded above and beyond to any concerns they raised. Staff also told us they felt that leaders led by example and embodied the values of the practice.

The PPG and care home representatives described leaders as exceptionally committed to the service. Representatives told us that leaders were visible, motivated, caring, and fostered positive relationships with staff and patients which created a culture of openness and trust.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements and policies in place. Staff were encouraged to share their views, were able to raise concerns and listened to. Staff told us they felt confident that their voices were heard and gave examples of changes that had been made based on their feedback.

The practice recognised the value of a diverse workforce and promoted a culture that was inclusive, fair and equitable. Systems and processes were in place to support equality, diversity and inclusion, with a strong focus on staff wellbeing and safety. Policies and procedures supported these objectives. Leaders provided examples of reasonable adjustments made for staff, including specialist equipment to enable them to carry out their roles effectively and flexible working arrangements to meet individual needs.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. There were detailed governance and management systems in place to support staff in the delivery of care. Staff could access all required policies and procedures.

During our assessment we found areas of risk that the practices processes had not identified. This included limited oversight of certain areas within the practice building, management of staff recruitment files and documentation of DNACPR decisions on patient’s clinical records. During our assessment, the provider submitted evidence that the governance systems relating to these concerns had been reviewed and as a result new processes had been implemented. The revised systems required further embedding to ensure information relating to risk, performance, and outcomes was consistently maintained.

Practice leaders met with staff regularly to complete appraisals and performance reviews. The practice held regular practice meetings with staff which were clearly recorded. Leaders ensured that minutes for the meetings were shared with all staff. Staff took patient confidentiality and information security seriously.

The practice clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Staff worked with other practices within their primary care network to offer extended access, flu, and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services.

Feedback from people using the service showed that the practice fostered positive relationships with local care homes, PCN colleagues, community providers, and the PPG to support integrated care and continuous improvement. The practice achieved this through regular engagement, joint working initiatives, and shared learning opportunities. Staff told us they felt leaders promoted a culture of openness, innovation, and partnership.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. Leaders encouraged staff to explore new ways of delivering person-centred care that promoted equality of experience, outcomes and quality of life. We saw evidence of a range of audits including reviews of clinical notes, cervical screening, diabetes and medicines including antibiotic and bisphosphonate prescribing. A quality improvement plan was in place to support ongoing service development and to help the practice respond to future challenges associated with projected local population growth.