Siam Surgery

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• 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

This key question has been rated as good. We looked for evidence that practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive and helped staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

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 practice had a shared vision and values based on safety, quality, compassion, integrity and development. Practice staff understood the challenges and the needs of people and their communities. Practice leaders were in the process of formalising their strategy and held regular business meetings where strategic issues were discussed, monitored and reviewed. For example, they had recently expanded 2 clinical rooms in the practice and planned to further increase space for non-clinical staff.

All staff we spoke with and received feedback from told us there was a supportive, inclusive, people and team focused culture and they were valued and supported by leaders.

The practice 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 we spoke with and received feedback from told us leaders were positive, enthusiastic and hardworking. Staff also told us leaders modelled the values of the practice.

Leaders were aware of the challenges of delivering safe, sustainable high-quality care. Effective arrangements were in place for workforce planning. For example, practice leaders had successfully recruited 2 GPs in the previous 6 months. Further recruitment was planned for improved managerial capacity.

One of the GP Partners was the Clinical Director of the Sudbury Primary Care Network (PCN). They worked with another practice in the PCN and were engaged in the development of primary care services within the local area.

Practice leaders fostered a positive culture where people and staff felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements and information was displayed in the practice.

All staff we spoke with and received feedback from told us leaders had an open-door policy and were visible and approachable. Staff were encouraged to share their views, were able to raise concerns and were listened to. Staff gave examples, which included requesting more time to complete work and changing the rota to enable staff to have lunch together, which were both implemented.

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

There were systems and processes in place to support workforce equality, diversity and inclusion, with an emphasis on the safety and well-being of staff. This included an equality and diversity policy and training for staff. Practice leaders raised awareness of anti-bullying week and encouraged staff to wear odd socks to work and explained why.

Leaders gave examples of reasonable adjustments in place for staff. These included for example, specific equipment to enable staff to undertake their role and flexible working to support staff with caring responsibilities, or attend counselling. Staff gave examples which included changes being made to rota schedules to support staff with religious beliefs.

The practice had clear responsibilities, roles and systems of accountability and governance. They had effective governance and management systems where information and data were used appropriately to monitor risk, performance and quality of care.They acted on the best information about risk, and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and staff were clear on their individual roles and responsibilities. The majority of staff we spoke with or received feedback from told us they could access all required policies and procedures and would ask if they were unsure of something. Staff were updated with changes in a range of ways. Staff took people’s confidentiality and information security seriously.

Managers held a range of governance meetings with staff, during which they discussed clinical concerns, performance, significant events, complaints and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff with lead roles fed back to the management team. Managers also had arrangements in place to supervise and monitor staff, for example, Clinical Pharmacists and Social Prescribers employed by the Primary Care Network (PCN).

The provider had recently submitted applications to add a new Registered Manager to carry on a new regulated activity, surgical procedures. They planned to start providing this when approved by CQC. This regulated activity was not being provided at the time of this assessment, so was not assessed.

Practice staff understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The practice met with local pharmacy leads to improve how they worked together for the benefit of people who used the practice. For example, the practice amended the text message to advise people their prescription had been sent to their nominated pharmacy, to advise people the pharmacy needed time to process the prescription before it could be collected.

The practice had worked with the Medical Examiner Service regarding Medical Certificates of Cause of Death (MCCD) before the commencement of this statutory service. Positive feedback was given regarding the professionalism of interactions and thoroughness, to ensure referrals contained all required information which saved time and minimised the risk of delay.

Partner agencies provided positive feedback regarding the engagement of practice staff with their community.

Practice leaders focused on continuous learning, innovation and improvement across the organisation and local systems. The practice trialled a new hospital discharge summary form and gave suggestions for improvement, which were implemented. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. There was a learning culture in the practice which staff and leaders actively encouraged and participated in.

Representatives from other organisations, which included advocacy and a local hospice, had attended staff meetings to provide training and share information. Health professionals who were not directly employed by the practice shared positive feedback about the openness of staff to learn from each other, for the benefit of people who used the service.

The practice had been accredited as a training practice for GP Registrars (qualified doctors training to become GPs) in June 2025. They had 1 GP trainer. They were currently supporting an Advanced Nurse Practitioner to complete the Advanced Practice Supervisor training programme. Stakeholders and partners gave positive feedback regarding how the practice worked collaboratively with them.