Causeway 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

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 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 treating patients fairly, equally with dignity and respect and to provide a highly effective, efficient and safe healthcare services for all patients and to listen, communicate and collaborate with patients effectively.

The practice had a mission statement which highlighted the practice’s mission was to provide high quality, patient centred services.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

The practice as a training hub for pharmacists and provided support and guidance for people studying independent prescribing.

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

Staff had access to clinical supervision, learning and development events as well as educational support and all staff had access to online learning systems.

There was an open culture and clear learning within the practice. Regular meetings were held with staff, and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

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 that their wellbeing was considered, and their views respected, and concerns acted upon. Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN 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 clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve.

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.

There were policies and procedures in place for the safe recruitment of staff. Other policies included equality and diversity, bullying and harassment and grievances[CP1][PW2].

All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were well supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available. Policies and procedures to promote diversity and equality were in place.

[CP1]Recruitment stated in first sentence

[PW2]Happy for this to stay as relevant to the QS judgement.

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

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.

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 practice carried out regular audits to monitor service provision and improve the quality of services provided. For example, medicine related audits, complaints and significant events.

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

Leaders told us they worked with stakeholders and the local community. The practice was part of a PCN which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

A patient participation group (PPG) was in place; and meetings were held on average every 6 months. We spoke with 1 member of the PPG who told us on average 5 people attended the meetings. The practice had engaged with the PPG on areas of improvement such as complaints, access and local services available.

The leadership team were aware there had been increases in demand and they were working with the PCN and stakeholders to ensure that resources were planned with continued collaboration and partnership working to meet the needs of the service.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The leadership team held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided.

The clinical team continually reviewed clinical guidelines and carried out regular audits to ensure patients received high quality sustainable care.

The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.