Gudge Heath Lane 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

Well-led - We looked for evidence that service leadership and management 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 Good. At this assessment, the rating has changed to Requires improvement.

The service was in breach of legal regulation in relation to good governance. The service's governance systems failed to identify and monitor compliance, as well as implement actions recommended in health and safety assessments. We also identified there was a lack of regular, documented clinical supervision instigated by a supervisor in line with service policy and national evidence-based prescribing guidelines to ensure staff were supported to carry out their roles.

However, the service had inclusive leaders at all levels who understood the context in which they delivered care. Staff were supported in raising concerns and had formal mechanisms to do so independently without the fear of retribution. The service focused on continuous learning to ensure service improvements and delivery.

This service scored 62 (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 staff had contributed to the development of the service’s vision and strategy, which was kept under review. The service was aware of the projected increase in the local population and was working with partner organisations to address future challenges. There were clear, established and effective systems and processes in place for leaders to share their vision, experience and support with colleagues.

Staff told us there was a positive team culture and they felt supported by GPs and senior leaders. They told us they were able to contribute to discussions about service improvements, incidents and complaints. All staff we spoke with were proud to work for the service and had a vision to deliver high quality care.

There were established and effective systems in place to promote a positive culture of learning, collective best service and performance. There was a mission statement developed by staff during annual TARGET training sessions. TARGET is a scheme aimed at improving care by learning new skills, sharing recommendations and incorporates quality improvement activities. The service’s mission statement and values were available and accessible to staff. Positive learning culture was demonstrated through meeting minutes which showed that performance, incidents, feedback and complaints were routinely discussed.

There were established and effective processes and systems in place for leaders to share their vision, practical experience and support with colleagues. This was achieved formally through governance meetings and clinical discussions.

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 at 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 GP practices in the primary care network and were engaged in the development of primary care services within the local area.

The service demonstrated oversight of clinical performance relative to workload and activity through risk rated parameters that were reviewed daily, including tasks related to outstanding results for people, referrals, medicine reviews, and triage requests.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements in place as well as a whistleblowing policy.

The service had oversight of themes and trends which included positive outcomes for people, including staff being treated equally. Where constructive feedback trends were identified, leaders told us there were plans in place to review staff wellbeing and these areas were placed on the service’s improvement plan. The service had set up new ways to support staff. For example, there was a forum where staff could share feedback and concerns informally. Additionally, there were extra communication channels to share updates about services, learn from experiences, and celebrate positive feedback through staff bulletins.

We reviewed the service’s incident management systems and processes, which demonstrated when something went wrong, people received an honest and timely apology and were told about any actions being taken to prevent the same happening again.

Staff were offered an employee assistance program (EAP) and the service had access to occupational health services where required.

There was a zero-tolerance policy in relation to the abuse of staff with mechanisms in place to protect people and minimise the likelihood of reoccurrence.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality for people who work for them. Policies and procedures to promote diversity and equality were in place. Mechanisms were in place to address concerns relating to discrimination. Adjustments had been made to ensure all staff were valued. For example, we noted there were reasonable adjustments in place to support the risks posed to the health and safety for workplace display screen equipment, ergonomics and movement and handling.

The service did not always have effective systems and processes to support good governance. Risks were not always effectively identified, assessed, or mitigated in areas relating to health and safety, fire safety, legionnaires and documented clinical supervision. Internal quality monitoring systems had also not identified shortfalls in these areas and they did not always act on information about risk. The service did not have fully effective and embedded processes for monitoring people’s health in relation to the use of some high-risk medicines, long-term conditions and safety alerts.

We identified there were examples of policies with no review date or version control such as clinical supervision, infection prevention and control, safeguarding adults and children. The service adult safeguarding policy did not state a named lead or local authority guidance and contact details contained, although we observed this information was displayed on posters within clinical rooms in the service. After the inspection, the service demonstrated updated service policies to contain version control and review dates for future oversight of service changes.

The service told us actions had been taken in response to the implementation of online triage systems to improve access to services. We determined routine and urgent care was provided to people to ensure they had effective and timely access to care and treatment with the right clinician at the right time. However, the service had not sought and documented assurances in relation to the artificial intelligence triage system to ensure this was safe to use in line with NHS digital standards. After the inspection, the service had demonstrated evidence of an updated policy which contained guidance of how the service deployed and used the digital technology, risk management, a named clinical data officer and how the technology developer was compliant with digital standards.

However, the service had a business continuity plan in place which gave guidance to staff for the preparation of major incidents. Staff were able to demonstrate how to access service policies and procedures and gave examples of how working arrangements had been adjusted due to past risks or incidents.

Information was stored securely in line with digital security standards with relevant information available in line with privacy, consent notices and general data protection regulations. This included how people’s data was used, choices regarding consent and how to protect online data through notices within the service, registration forms or online via the service’s website.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners including community teams and external stakeholder healthcare providers.

The service worked with other GP practices within their local primary care network to offer extended access appointments, such as for cervical screening, leg ulcer clinics and vaccination programmes. Staff made adjustments to improve coordination with community healthcare services. This included establishing regular multi-disciplinary team meetings. These meetings focused on the care of people at higher risk of hospital admission, as well as those who are frail or vulnerable.

Staff told us they had strong relationships with healthcare professionals within the local community to support care provision and joined-up care. Staff spoke positively about the work that was happening in the local community such as home visiting teams and were proud to have made an impact. Community providers shared positive feedback about their experience working with the service, in conjunction with the primary care network. They highlighted a collaborative approach to monitoring and delivering care tailored to people's needs. This included support for individuals with poor mental health and those receiving end-of-life care.

The service focused on continuous learning, innovation and improvement across the organisation and the wider local health and social care system. They encouraged creative ways of delivering positive outcomes and experiences for people.

The service had a program of quality improvement audit activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example, there was a clear plan for conducting clinical and non-clinical audits. Outcomes and learning were shared with staff to ensure future recommendations were implemented.

The service was listed as a training practice which helped support GP registrars.