Napier Road 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 is the first inspection 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.

The service had a mission statement displayed in the reception area of the practice and staff were aware of the practice’s current vision and strategy.

The service was aware of the potential future changes in the local population and were working with their primary care network (PCN) to address future challenges.

Staff spoke positively about the culture of the service and why it was a place they wanted to work. For example, staff shared positive feedback about a supportive working culture from working in a small team.

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

Leaders worked with other practices in the primary care network (PCN) and were engaged in the development of the PCN in the local area.

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

The service had established Freedom to Speak up arrangements with other practices in the PCN. Staff knew how to raise concerns. However, there were no examples where staff had needed to use these arrangements.

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 available. Leaders told us any discrimination would not be tolerated. Leaders were open to all possible changes that could enhance the experience of staff so that they felt valued and included so that they could thrive at the service.

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 share this securely with others when appropriate.

Leaders supported staff, and all staff were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The service had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Leaders 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. Staff took patient confidentiality and information security seriously.

However, the service was unable to evidence they had oversight systems for staff training. While staff records, we reviewed demonstrated that staff were up to date with training, the service was unable to demonstrate how they maintained oversight of this. Leaders told us that training oversight was maintained using an e-learning system, but this was unavailable at the time of assessment. We were shown a spreadsheet for monitoring training that leaders told us they used, however this did not align with the mandatory training staff were required to complete.

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 service worked with other services in their PCN to offer extended access for appointments which included vaccination and screening appointments. Leaders shared outcomes and learning from incidents to improve outcomes for neighbouring services connected to the PCN.

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.

All staff were encouraged to put forward and test out new ways of working. For example, reception staff provided input on a new proposed Hormone Replacement Therapy (HRT) referral process as they felt it could be optimised to improve the coding of people on their computer system. Leaders were open to these views and supported reception staff in raising how they would implement the changes.