Beeches Surgery Also known as Drs Froley & Ghoorbin

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 practice 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 Inadequate. At this assessment, the rating has changed to Good.

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 practice 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.

At our last inspection we received mixed responses from staff in regard to morale, with concerns expressed about staffing levels which meant some staff were required to undertake compulsory overtime.

During this assessment staff told us that overtime was entirely voluntary and that recruitment of additional staff in key roles supported other staff in their work. Staff were able to undertake voluntary overtime but were not required to do so.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. Staff told us there was a positive, compassionate, no blame culture at the practice. They also said learning was encouraged and discussed at monthly clinical meetings but also during quarterly clinical supervision meetings. They also mentioned that the practice ensured staff felt heard and valued.

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.

At our last inspection we found that there were regular gaps in management cover, and a lack of commitment to succession planning with unactioned plans for development of the partnership.

At this assessment we found that the practice had closed earlier gaps in the management structure and had recruited a managing partner. However, the partner had not completed the application process to CQC to be added to the partnership. We also found that there had been no Registered Manager for the practice since April 2021. We raised this with the practice and an application was submitted to CQC during the assessment period.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. Staff told us, leaders were visible, approachable, and responsive and there was a clear structure in place, including lists/charts that outlines individual roles, such as safeguarding leads and duty doctor rota.

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

The leaders told us that they acted with openness, honesty, and transparency with staff.

The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect. There was a Freedom to Speak Up policy and named Freedom to Speak Up Guardians available to discuss any staff concerns.

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

Policies and procedures to promote diversity and equality were in place. For example, the equality, diversity, and inclusion and bullying and harassment policies set out how the practice prevented discrimination, harassment, or bullying.

We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff with protected characteristics were in place.

The practice 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.

At our last inspection we found gaps in the management structure and staffing issues placed pressure on other staff. There was also a lack of a structured and systematic programme of clinical audit where results could be used to drive improvements and monitored by repeating the audit cycle.

At this assessment we found the practice had addressed earlier concerns regarding management structure, staffing levels and had introduced a programme of clinical audit.

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 practice. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks.

The practice 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 services within their primary care network to share best practice, training opportunities and quality improvement projects.

Staff had made adjustments to improve coordination of their practice with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The practice 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. For example, the practice had introduced a care navigation system at reception, which helped direct patients to the most suitable professional: including GPs, nursing staff, pharmacist, or community service. This had reduced waiting times for GP appointments and made better use of clinical staff time.

The practice had a quality improvement plan in place to help drive improvements in services This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working. This was encouraged by making time in meetings to raise ideas together with informal opportunities to speak to colleagues and managers.