Dr John Segarajasinghe Also known as The Pine Street Medical Practice

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 practice had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of patients and their communities.

Leaders had clearly set out roles and accountabilities, ensuring responsibilities were understood at every level of the practice. Staff had contributed to the development of the practice’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

Staff reported that they had felt well supported by the GP partners and practice Leader and were able to raise concerns and suggest improvements. Staff told us that they had felt listened to and described the team as supportive and collaborative. Feedback about leaders had been consistently positive, and a positive and inclusive working culture was described across the practice.

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 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. 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.

Staff described feeling valued and motivated in their roles, with leaders who listened and recognised their contributions. Staff told us they felt included and supported. They said Leaders were approachable and encouraged them to share ideas or raise concerns. Staff referred to the culture within the service as a “family environment”, with support provided across the whole team.

Regular meetings and supervision sessions were provided to enable staff to reflect on their practice, learn from colleagues, and maintain a focus on the needs and preferences of patient receiving care and support.

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

The practice had established Freedom to Speak Up arrangements and both a Whistleblowing Policy and a Freedom to Speak Up Policy and staff knew how to access them if they wanted to raise a concern formally. These included details for the practice’s Freedom to Speak Up Guardian, as well as information about organisations staff could contact outside of the service if they felt they needed to.

Staff were aware of how to raise concerns, staff described an open-door culture where they felt supported, and they felt confident in raising any concerns. Regular team meetings and supervision sessions gave further opportunities for staff to talk openly about their experiences.

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

Policies and procedures to promote diversity and equality were in place. Staff came from a range of backgrounds, cultures and nationalities and worked together in a respectful and inclusive environment. Staff told us they felt valued and supported regardless of their personal characteristics, and the practice promoted equality of opportunity for both male and female staff.

Training in equality and diversity was provided, and staff understood the importance of creating an inclusive environment both within the workplace and in the care they delivered.

Overall, 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.

The practice had updated its recruitment policy prior to the inspection to strengthen pre-employment checks; however, the changes had not yet been reflected in all staff recruitment records, as some files related to staff recruited before the policy revision.

During our assessment we found areas of risk that the practices processes had not identified. This included that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) had not been coded within the patient’s clinical record.

Overall governance systems supported the monitoring of medicines safety, including the management of safety alerts, medicine recalls, and documentation of medication reviews. Clinical searches provided assurance that most monitoring and follow-up processes were done effectively. However, gaps were identified in the oversight of some prescribing and monitoring arrangements, including overdue reviews and blood tests for a small number of patients. In addition, prescribing levels for hypnotics and antibiotics were higher than expected and had not been routinely monitored. The practice acknowledged these findings and stated that prescribing trends would be reviewed to support learning, improvement, and safer prescribing.

Leaders and Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews. The practice 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. Leaders 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 work in partnership, so services work seamlessly for patient. They share information and learning with partners and collaborate for improvement.

The practice worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The practice worked with the Patient Participation Group (PPG), and meetings were held both in person and virtually. Efforts were being made to broaden engagement with the local community and to support wider participation in the development of services.

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 patient. They actively contribute to safe, effective practice and research. We saw evidence of clinical and non-clinical audits, including medicines optimisation audits for diabetes and audits relating to weight management treatments.

Leaders promoted a positive learning culture in which staff at all levels were encouraged and supported to develop their skills, knowledge, and competence. Learning was shared effectively and used to make improvements across the service. There were well-established systems to learn and reflect from incidents, updates, and staff and patient feedback.

The continual development of staff skills, competence and knowledge was recognised as integral to ensuring high quality, safe care, improved access and sustainability. Staff were actively supported to acquire new skills, develop and share best practice. Staff told us they felt valued and supported and spoke positively about the development opportunities available to them.

A quality improvement plan was in place to support ongoing service development and to help the practice respond to future challenges associated with projected local population growth.