Custom House 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 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 service demonstrated a shared vision and culture rooted in transparency, equity, diversity and inclusion, engagement, and a strong understanding of the needs and challenges faced by its communities. Leaders operated an open‑door approach and were described by staff as approachable and supportive. Staff told us they felt safe raising concerns and were confident they would be listened to. Where people were affected by things going wrong, the service provided apologies and clearly communicated the actions taken in response.

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.

The service had policies and procedures which supported a learning culture. The service offered apologies to people, learned lessons from individual concerns and complaints, and took action to improve the quality of care. Staff had clear roles and responsibilities and had shown flexibility to meet patients' needs.

The service fostered a positive culture where people felt they could speak up and that their voice would be heard. Staff we spoke with felt that leaders were approachable, listened, and acted in response to matters raised.

The service valued diversity in its workforce. Leaders worked towards an inclusive and fair culture and staff told us they work well as a team and supported one another.

The service had clear responsibilities, roles, systems of accountability, and good governance. These had been used to manage and deliver high-quality, sustainable care, treatment, and support. Leaders had acted on the best available information about risk, performance, and outcomes, and had shared this securely with others when appropriate.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 appropriate for the service. Staff had access to all required policies and procedures.Managers held regular meetings with staff to discuss clinical concerns and emerging risks. Any actions arising from these meetings had been clearly recorded and shared with staff. Staff had taken patient confidentiality and information security seriously, supported by relevant policies and procedures. All staff had completed GDPR training.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service’s social prescribers and health and wellbeing coach collaborate with external organisations to support patients’ overall health and wellbeing. They deliver educational sessions on self-awareness topics such as prostate and breast cancer and run digital skills training in partnership with the local library.

The service engaged with other practices in the Primary Care Network, to share the outcome of their last inspection and worked with the other practices to drive improvement in how clinical care is delivered and monitored, using the clinical searches developed for our inspection methodology.

They 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. They actively contributed to safe, effective practice and research.