Ladygate 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, 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 and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff had contributed to the development of the practice vision and strategy and when interviewed demonstrated the values of the service. The practice worked with partner agencies to address future challenges within the local community.

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.

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

The practice had established Freedom to Speak up arrangements within the practice and externally with Hillingdon confederation. Staff were aware of how to raise concerns and were confident to speak up without fear or detriment.

The service valued diversity in their workforce. They work 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. Adjustments had been made to ensure all staff were valued. For example, in response to staff feedback about workload and the demands of working on reception, the practice introduced dedicated administration time away from the reception desk to help ease the pressure on staff.

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.

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. The provider had established governance processes that were appropriate for their service. Staff could access all 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 worked in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Staff had made adjustments to improve coordination of their service with community healthcare services to support patients with more complex conditions at home.

The practice had an active Patient Participation Group (PPG) who met annually at face to face meetings. Representatives from the PPG informed us those meetings were structured and with an agenda, with the most recent meeting covering updates on staffing, the telephone system, online consultation service (known as Patches), the practice website, appointments and extended hours hubs in the locality.

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, and we saw examples of this following staff well-being meetings in 2024 and 2025.