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

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

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 were aware of the practice vision and strategy, which was displayed throughout the practice and kept under review. Staff were very positive about the culture within the practice and described it as open, transparent and supportive. Leaders told us they fostered a just culture across their organisation and encouraged staff to raise any concerns or suggestions for improvement they may have. For example, when staff were concerned about the hot weather, they installed a water cooler to support staff and keep them hydrated and provided portable fans throughout the practice.
 

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 was extremely approachable and responded quickly 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. The practice was 1 of 8 practices managed by the provider. The registered manager attended the practice at least monthly, and staff were aware of how to contact them if they needed to do so. Systems were in place for the practice manager to meet with the provider on a regular basis.
 

The service fostered a positive culture where staff felt they could speak up and their voice would be heard.

The provider had established Freedom to Speak up arrangements within their wider organisation. All the staff we spoke with were aware of who and how to contact the guardian. A policy was in place to support staff if they needed to raise any concerns with the guardian.
 

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued. For example, we found that a risk assessment had been completed to support a member of staff with a long-term condition in the event of a medical emergency.
 

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.

The provider told us that governance originated at practice level and escalated upwards, rather than directed downwards from head office. The practice held its own clinical governance meetings where risks, incidents, and audit findings were reviewed. Unresolved matters, or those with organisation-wide implications, were escalated to the senior management team, which held ultimate accountability for safety and quality.

The provider’s mission statement was to ensure that NHS primary care had a sustainable future. There were clearly defined steps on how they would achieve this. Operational tasks were centralised at their head office with dedicated teams working it specific areas, for example triage of appointments, workflow and resourcing. They had, or were in the process of developing, their own IT systems to track and support the overarching governance of the service and establish personalised care pathways. There was an overarching risk register in place which was reviewed with the practice monthly. Arrangements were in place to monitor and improve the quality of the service for example, a rolling programme of clinical audits and quality improvement projects.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all the required policies and procedures. 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 service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. They worked closely with the Primary Care Network (PCN) to provide health promotion and well-being drop-in clinics.

We received very positive feedback from a care home where the service, alongside the PCN, delivered care and treatment. They told us they could not fault the practice, and they were responsive to the needs of people living in the home. They told us they wished the practice provided care and treatment for all the people living in the home.

A patient participation group (PPG) was not in place to represent the views of people using the service. The service told us they had were trying to re-establish this.
 

The service 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. They used complaints and significant events to drive improvement within the service.

The practice had a quality improvement plan in place to help drive improvements in services. There was a proactive programme of clinical audit covering medicines safety, long-term condition management, vaccine storage, and patient access. A system of re-audit was in place to monitor that improvements made, had been effective. Clinical audit meetings were also held on a regular basis, and an action and assurance log was maintained to monitor the effectiveness of the audits. The practice has completed a Duty of Candour process following a delay in acting on an abnormal blood test result. Together these showed the practice identified risks and acted on them.

The practice had developed their own technology and IT systems to co-ordinate the recall of patients for annual reviews and the management of triage and workflow.