Baddeley Green 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

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. Improvements were noted between the first and second cycle clinical audits demonstrating continuous learning and improvement in patient outcomes. Staff felt supported to give feedback. Staff understood their roles and responsibilities. Staff fed back the practice was a good place to work.

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 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 the leadership team in the practice were approachable and responded to any concerns raised. However, staff told us improvements could be made in the integration of and communication within the team as a whole.

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.For example, we saw positive feedback from the local and community team on the practice lead GP as a learning disability champion presentation at an event in 2024.

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 the leadership team in the practice were approachable and responded to any concerns raised. However, staff told us improvements could be made in the integration of and communication within the team as a whole.

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.For example, we saw positive feedback from the local and community team on the practice lead GP as a learning disability champion presentation at an event in 2024.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had access to a Freedom to Speak up Guardian and an accessible policy in place. Staff were aware of how to raise concerns.

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

Policies and procedures to promote diversity and equality were in place. The leadership team authorised numerous flexible working requests for both clinical and non-clinical staff and were responsive to any changes to working as a result of staff disabilities. Staff reported that they could speak without fear of breach of confidentiality with the practice manager. Staff reported that they would discuss their working hours with the manager or lead GP if they needed greater flexibility in their role or needed to change.

All staff we spoke with were clear on their individual roles and responsibilities. Leadership met with staff regularly to complete appraisals and performance reviews.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. The leadership held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Leaders recorded any actions arising from these meetings and ensured they shared these with staff. However, we found gaps in some of the systems and process in place. For example, reception staff inductions and care navigation prompts, some environmental maintenance checks, prescription security systems, medicine stock levels and a few gaps were noted when we completed our clinical searches. The leadership were responsive to our findings, acted upon these promptly and provided evidence of the actions completed and risk mitigated.

Staff took patient confidentiality and information security seriously. Services and staff with the Whitfield Primary Care Network (PCN) were subject to a memorandum of understanding agreement and regular PCN meetings took place. The PCN also held a pharmacy hub steering group meeting to which summary minutes were taken andappropriately shared. Leaders ensured minutes of meetings were circulated and communicated with the whole practice team via email. Policies were circulated to staff and saved on the practice electronic shared drive. Clinicians were responsible for any notifications to statutory bodies and data protection and confidentiality policies were in place as well as staff information governance training.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes.

The Patient Participation Group (PPG) reported the practice was highly valued in their community. They reported on a positive relationship between the PPG and the practice leadership team built upon mutual respect. Leaders attended and supported the PPG in their role at their regular meetings. The PPG were proactive in providing feedback and gave examples on the responsiveness of the leadership team to this feedback.

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.

The practice had processes in place for quality improvement such as clinical audits. There had been a range of clinical and medicine audits completed in 2024. These included for example, second cycle audits on suicide and self-harm risks, safer paracetamol prescribing in patients whose weight was within a specific low weight range, infection control audit, and a prostate-specific antigen (PSA) test audit. Improvements were noted between the first and second cycle clinical audits demonstrating continuous learning and improvement in patient outcomes.