Oakwood 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 remained the same.

This service scored 68 (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.

All leaders we spoke with demonstrated their commitment to achieving their vision and strategy. Wellness was seen by managers as a leadership responsibility, and it was a shared value for all staff.

Staff demonstrated understanding of the service’s vision and commitment. Values included taking ownership, having a person-centred approach and being team oriented.

There was a positive and compassionate listening culture that focused on learning and development. We reviewed staff feedback the service had collected.

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 service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. We saw the leadership team worked with other services in the primary care network and were engaged in the development of primary care services within the local area.

There were high levels of staff satisfaction. Staff were proud to work at the service and spoke highly of the culture. There were consistently high levels of staff engagement. Staff at all levels were encouraged to raise concerns and feedback.

The continued development of staff skills, competence and knowledge was recognised as integral to ensuring high-quality safe care, improved access, and service sustainability. Staff were proactively supported to acquire new skills, develop and share best practice.

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

The service had a Freedom to speak up guardian. All staff we spoke with were aware of how they could raise concerns. They told us that they would feel confident to go to leaders with concerns.

Staff we spoke with said, managers had an open-door policy, colleagues were supportive, and they felt able to have difficult conversations if they were required.

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

Policies and procedures to promote diversity and equality were in place. 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 disabled staff were in place.

The service had clear responsibilities, roles, systems of accountability and governance. However, arrangements for identifying, managing and mitigating risks were not consistently effective. During the inspection, we identified concerns relating to the management of controlled drugs and missing emergency equipment and medicines that had not been detected through routine governance processes. The management team responded promptly to these findings, took our concerns seriously and undertook an immediate review of governance arrangements in these areas.

Governance processes were generally embedded within the day-to-day operation of the service. There was a framework of accountability to monitor performance, quality and risk, which had supported demonstrable improvements. Audits and clinical searches demonstrated that governance and performance management systems were regularly reviewed and were aligned with current guidance and best practice.

However, the fact that key issues were identified during the inspection rather than through the provider's own assurance systems indicates that governance oversight was not always sufficiently robust. This was further reflected by gaps in the oversight of emergency medicines, incomplete recording of medication reviews, inconsistent monitoring of clinical outcomes, lower-than-average patient experience regarding access, and challenges in achieving key population health indicators. Collectively, these findings demonstrate that while governance systems were established and generally effective, they did not always enable leaders to identify, monitor and address risks in a timely and comprehensive way at the practice.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. They told us there was a culture where they were encouraged to develop.

Leaders and managers promoted positive accountability, support, and sustainable improvement across the organisation. They 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 service 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 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 offer extended access, and flu and covid vaccination programmes.

The service was veteran accredited, where veterans are proactively identified ensuring they are signposted to appropriate support and priority pathways where needed.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service demonstrated a commitment to improvement however, quality assurance processes were not sufficiently effective in identifying risks or capturing learning to drive sustained improvement. For example, we identified gaps relating to medicines management not detected through the provider's own audit system. Access to the service and below target childhood immunisation and cervical screening uptake had not been adequately addressed despite being identified at the previous inspection, indicating limited learning and improvement over time.

The service demonstrated that learning from some significant events had resulted in changes in policy. For example, the leaders shared learning from an event relating to a patient attending an extended access appointment where it was identified they required an NHS 2-week wait (2WW) referral. This is an urgent request from the GP to see a hospital specialist to rule out serious conditions like cancer. The referral request was not shared with the GP practice by the extended access team and therefore there was delay in the referral being made. The leadership team reviewed the policy and agreed with the extended access team they would notify the surgery directly if any urgent referrals were needed. The leadership team spoke with the other services within the Primary Care Network and shared the updated policy.