The Blundellsands 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

Leadership, management and governance arrangements supported the delivery of high-quality, person-centred care. There were clear systems in place to help ensure care was delivered safely and effectively. Leaders showed they were capable, compassionate and inclusive, and placed a strong focus on workforce equality. Staff understood their own roles and those of their colleagues, and lines of accountability were clear. Staff told us they felt well supported in their roles.

There was an open and honest culture within the organisation. Leaders gave staff information about how to raise concerns and felt confident that any issues would be listened to and acted on. Leaders encouraged learning and innovation and a good understanding of the challenges facing the service in terms of quality and sustainability.

Information was used well to monitor and improve the care provided. However, some aspects of record-keeping and data management were not as well maintained as they should have been. We discussed this during the assessment, and the practice was open and responsive to our feedback, acting immediately to make improvements.

This service scored 79 (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 which was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively. Staff spoke of a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. All staff we spoke to felt positive about working at the practice and feedback from staff questionnaires was consistently positive about working at the practice. They described good teamwork and a service that was clear on its function to work in the interests of patients and providing the best patient experience they could. Regular meetings were held for clinical and non-clinical staff. Members of the team told us that communication was effective but could be improved to ensure that all team members received the right information at the right time in the right way.

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 practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw 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.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They monitored and acted upon data about outcomes for patients and made improvements when required. Feedback from people who used the service was very positive with regards to the capability and compassion of the staff and leadership team.

The practice had appointed a Freedom to Speak Up Guardian within the practice who was not part of the leadership team, but someone staff described as “easy to talk to.” Staff told us they knew how to raise concerns, felt confident in doing so, and believed their concerns would be taken seriously.Leaders stated that they encouraged staff to speak up, promoted a culture of openness, and had policies and procedures in place to support this.However, there was no designated individual external to the practice whom staff could approach if needed.

The provider valued diversity within the workforce and actively promoted an inclusive and fair culture by supporting equality and diversity among staff. Reasonable adjustments were made to help staff carry out their roles effectively. The provider supported staff with caring responsibilities through flexible working arrangements and adjusted schedules to meet their needs. Staff had completed training in equality, diversity, and inclusion and demonstrated awareness of how to support individuals with protected characteristics, such as age, gender, religion, and disability. There were no concerns reported regarding workforce equality at any level, including recruitment. The practice had an established equality, diversity, and inclusion policy in place.

There were clear and effective arrangements in place for governance, management, and accountability. The provider used data to monitor performance and drive improvement. All staff we spoke with understood their individual roles and responsibilities. Managers held regular meetings with staff to complete appraisals and performance reviews. A regular programme of clinical system searches was carried out to identify patient needs and ensure these were addressed, and our review of clinical records showed this was mostly effective. Staff were able to access all necessary policies and procedures and demonstrated an understanding of patient confidentiality and information security. There were systems in place for identifying, managing, and mitigating risks, and a major incident plan was in place. The provider had established governance processes appropriate to the service.

However, some areas for improvement were identified, including task management, learning from events and complaints, maintenance of records, and medicines management. During the assessment, we were assured that the provider took all identified issues seriously and acted on them immediately.

The provider demonstrated a clear commitment to collaboration and partnership working to ensure services operated seamlessly for patients. They shared information and learning with partners and engaged in joint initiatives to drive improvement. The provider worked with other practices within their primary care network to deliver extended access services and to coordinate flu and COVID-19 vaccination programmes. They also collaborated effectively with external stakeholders, commissioners, and partner agencies to provide and enhance service delivery. The Patient Participation Group (PPG) worked with the practice to actively improve services for patients.

The provider had a focus on continuous learning and improvement across the service, with There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence.

The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.

Leaders told us they maintained strong external relationships that supported improvement and innovation.

The practice was proud to be part of, and work with the South Sefton Primary Care Network (PCN) who were awarded PCN of the Year in 2024.

The practice had developed and implemented a document management system that was initially piloted within the PCN and subsequently adopted at a national level. Its flexibility allowed it to be adapted to meet both clinical and non-clinical needs, leading many GP practices to adopt the system independently.

The practice had received Veteran Friendly Accreditation, a Pride in Practice Gold Award for its work in supporting the LGBTQ+ community and was also recognised as a Dementia Friendly Practice.

The practice was part of the first PCN-wide Unified Learning Environment (ULE), having participated in a pilot with Health Education England (HEE). The initiative was led by the practice lead who was also the PCN lead. As part of the ULE, the practice provides training for GP Specialty Trainees (GPSTs) and an Advanced Clinical Practitioner (ACP).

The practice had been training GPs for more than 25 years nurses were supported to become non-medical medical prescribers.