Ilford Lane 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

The practice's vision was delivering a safe service and continuously reviewing and improving care. This was published on its website and consistently described by staff. Strategy was visible in concrete action. For example, services affected by commissioning gaps, including phlebotomy and spirometry, had been brought in-house and funded directly by the practice rather than waiting for external provision to be restored.

Vision and strategy were shaped through ongoing dialogue with people who used the service and with external partners. A structured Patient Participation Group met regularly, with minutes reviewed and approved and actions tracked. The lead GP briefed members transparently on funding pressures, staffing changes, and service developments, and responded directly to member concerns, including about difficulty securing GP appointments. The practice also described active partnership work with the primary care network, community teams, mental health services, social care, and voluntary organisations to support more joined-up local care.

Staff consistently described an open, warm, and close-knit culture, with management accessible and Freedom to Speak Up embedded. Staff said they were never made to feel pressured or afraid to raise concerns, and were given extra time and support when needed. Mandatory equality, diversity, and inclusion training had been completed by all staff.

Changes were communicated through a combination of practice meetings, email, and a shared drive, discussed with staff before implementation. Progress and culture were monitored through an annual anonymous staff survey and through practice and Patient Participation Group meetings. Workload pressure was identified as the main risk to delivering further planned expansion of in-house services, though this had slowed rather than stopped progress.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Day-to-day accountability was distributed across named leads. For example, infection prevention and control with the nurse, health and safety with the practice manager, and safeguarding, prescribing, and most clinical leadership with the lead GP. Each lead was confirmed independently across interviews. However, the lead GP said no formal governance lead role or dedicated governance meetings were yet in place, describing this as a next step. A risk register was in place, and a formal, consolidated list of named lead roles and responsibilities was still being produced at the time of our assessment. A broader organisational governance structure document was in development and seen during the visit.

Policy and standard operating procedure oversight ran through the dated policy register with annual review cycles. The practice had a subscription to relevant services flagging legislative change. This extended to data governance specifically. For example, a data security and protection toolkit handbook, a Caldicott and confidentiality policy, and a confidential waste policy were all in place and logged with annual review dates, alongside the call-handling confidentiality practices described under Kindness, Compassion and Dignity.

A significant event log was in place and used in practice. For example, a wrong-patient immunisation incident was logged, the patient notified, and the action recorded. Information from quality improvement auditsand from national survey benchmarking against other local practices, fed into practice meetings, which was observed in meeting minutes.

Leaders responded to this assessment with notable speed and substance, producing missing documentation. For example, an audit action log, a consolidated list of named lead roles, and a shared direction and culture policy, and evidencing structured action plans in direct response to survey, access and complaints findings. This reflected a leadership team treating the assessment as a driver of improvement rather than a compliance exercise.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.