Hall Green 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 outstanding. At this assessment, the rating remains the same.

This service scored 100 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. A regularly updated business plan took account of all aspects of development.

There was a clear mission statement, and the vision showed aspirations to provide the highest possible standard of professional interaction to people, staff and the wider community and deliver high quality care innovatively. Staff were positive about the culture within the service and described it as open and transparent.

The practice told us, they had whole practice meetings, which gave an opportunity for all staff to speak and was held within protective learning time. There were also regular meetings of the Primary Care Network (PCN) to provide an open platform for discussion.

The service had exceptionally 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 always did so with integrity, openness and honesty.

Staff reported that all leaders were approachable and responded to any concerns raised. They also told us leaders modelled the values of the practice. The practice manager worked closely with supervisors to promote a team environment. We saw the leadership team worked with other practices in the PCN. Staff told us managers and partners were visible, and they gave several examples of leaders being supportive.

Leaders had an open-door policy, and staff stated they felt comfortable going to managers about any problems or concerns. Honest feedback was encouraged at all levels, and staff had received training to ensure they felt confident in reporting incidents and suggesting changes. The practice manager actively requested feedback from staff.

The practice had a positive culture where people knew they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with a clear and detailed policy staff could follow. Staff confirmed they were aware of how to raise concerns outside of the organisation. Staff had received training in whistleblowing.

The practice strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved 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. The practice was an equal opportunities employer and staff reported feeling supported, valued and informed. Adjustments had been made to ensure all staff were valued.

The practice provided training, and maintained policies, relating to bullying and harassment.

The practice had registrars within the practice from different countries. They ensured culture and beliefs were embraced. For example, they had a designated prayer room when required. They also proactively amended clinic and break times to allow people to safely fast when required.

The practice had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and share 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 that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice 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 practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and for improvement.  The provider worked with other practices within their primary care network (PCN) to offer enhanced access appointments.

The practice had an active Patient Participation Group (PPG) who met annually at face-to-face meetings. Representatives from the PPG informed us those meetings were structured and with an agenda. The PPG were proactive in providing feedback and gave examples on the responsiveness of the leadership team to this feedback.In addition to annual meetings, the PPG met as a group within the community to promote health initiatives.

The practice had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. All staff were encouraged to put forward and test out new ways of working.

The practice had embedded processes in place for quality improvement such as clinical audits. There had been a range of clinical and medicine audits completed. These included for example, prostate cancer and cervical screening audits.

The practice had a plan to be an accredited Green Practice, actively working to reduce its environmental impact by implementing eco-friendly initiatives. Examples were provided of their current and planned initiatives.

The practice had worked to become a Safe Surgery. Safe Surgeries recognise the healthcare barriers that exist, particularly for migrants in vulnerable circumstances. They were working to ensure nobody in their community was excluded, so that immigration status, language, or a lack of ID, was not a barrier to registering with them.

The practice had a strong and clear awareness of their local population demographics, including hard to reach vulnerable groups of patients.