Archived: Langstone Way 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

We assessed a total of 3 quality statements from this key question. 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 inspection, we rated this key question as Inadequate. At this assessment, the rating has changed to Requires Improvement. This is because we found that the surgery had improved their governance in most areas since the last inspection held in 2023. For example, a schedule to the management of policies to govern the surgery had been implemented to allow review and amendment according to changes within surgery. However, we also found areas for improvement for example, some processes such as clinical audits did not always identify improvement to patient outcomes. The surgery leaders had a vision and strategy in place, but it was not clear if the vision and strategy had been embedded and shared amongst all staff, which would drive the culture at the surgery. While leaders understood most challenges affecting the service, the oversight of the day-to-day running of the surgery, staff support and risks affecting the provision of service were not always acknowledged. We reference risk in relation to the low attainment scores achieved by the surgery in the most recent published GP Patient Survey.

Our last assessment for this provider in 2023 we rated the provider as Inadequate for key question Well-Led. At this assessment, the provider has shown improvement within this key question and as such, the rating for this key question moves from Inadequate to Requires Improvement.

The service was in breach of legal regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us that there was an open and inclusive culture at the surgery, and this was confirmed by staff members we spoke with.

The GP provider and the practice manager held regular meetings to discuss practice performance, but these discussions were informal and not recorded.

The leaders (GP provider and Practice Manager) understood the context in which the surgery delivered care, treatment and support, speaking with us about the challenges around funding, staff changes and increased workloads.

Staff we spoke with said they were comfortable in making their views heard and there were opportunities to do so either in staff meetings or privately with managers.

The surgery had a vision and strategy, but this was not formalised, and further work was required to embed these so that they became part of the culture at the surgery. Not all staff we spoke with knew what the vision of the surgery was.

The surgery had a disaster recovery plan to allow them to operate under exceptional and adverse circumstances.

The surgery had policies and procedures in place that promoted workforce equality, diversity and inclusion.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The surgery did not always have clear systems of accountability and good governance. Although the surgery had assurance and governance policies and procedures in place, this assessment found improvements in systems and processes were required for medicines management, staff appraisals and ensuring all staff kept up to date with required training, as set by the surgery.

The surgery did not have a plan of action to address and improve patient perception of care delivered following the publication of the most recent GP Patient Survey results. Patient access concerns had been discussed with the surgery at our inspection held in 2023.

The surgery had a freedom to speak up guardian for staff.

The GP provider had officially moved from being a partnership to becoming a sole provider of services since our 2023 inspection, and they spoke with us about the various ways that they hoped to make the work of the surgery sustainable. We identified that the previous GP partner still worked ad-hoc at the surgery, but there was no job description for this individual and therefore we were not able to understand what role they were undertaking whilst working at the surgery.

We spoke to the surgery about this during our assessment and following on from this discussion, we received a job description for the individual concerned.

There was a whistle-blowing policy in place, and this was accessible electronically to all staff.

The surgery had policies and procedures in place that promoted workforce equality, diversity and inclusion.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

During the assessment we found the surgery focused on continuous learning, and improvement but were unable to describe areas of innovation. The surgery had complied a shared resource electronic folder, which provided information and guidance to staff on a range of clinical and non-clinical subject relating to patient care.

We did not look at processes as part of this quality statement. The score for this quality statement is based on the previous rating for Well-Led.