Cutlers Hill 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 the surgery 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 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The surgery had a very clear shared vision, strategy and culture. This was backed up by the staff and leaders at the surgery during the onsite visit and was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders demonstrated an understanding of the challenges and the needs of people and their communities. They carried out patient surveys to understand their population’s needs. Services were then tailored to their population age demographics and the rurality of the surgery which led to positive National GP Survey results. We saw the surgery continued to provide services that were no longer funded within the GP contract to ensure people did not need to attend urgent care or secondary care services. The surgery keeps their online booking service open 24 hours a day, so people do not have to wait for the core hours to communicate or request an appointment, which is outside contract provision. The surgery continues to provide cancer care reviews annually although no longer obligated to through the quality outcome framework. Despite GPs no longer being paid for shared care agreements they still monitor people to ensure they can receive their care and treatment at the surgery.

All the staff we spoke with felt they had been able to contribute to the development of the surgery’s vision and strategy, which leaders kept under regular review. Leaders monitored and reviewed the progress against the delivery of their surgery strategy. The surgery was aware of the local challenges which affected the service they provided, such as the projected increase in the local population over the coming years and worked with partner agencies to address these challenges. For example, they had worked tirelessly to get permission and funding for an extension to their building which had been agreed, with plans visible within the waiting area to inform their population about the work to be undertaken. Staff and leaders actively promoted equality and diversity and worked to identify any workforce inequalities. The leaders and staff all demonstrated a positive and compassionate listening culture that focused on learning, development and providing good quality safe care and treatment.

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 had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

All staff we spoke with were clear on their individual roles and responsibilities. Staff told us leaders proactively supported and regularly met to complete appraisals and performance reviews. The leaders and management had established governance processes in relation to the quality statements that we reviewed during this assessment. These were effective and appropriate for the services provided at the surgery. For example, we were provided a document that aligned the work carried out against the quality statements to provide assurance of their achievements. Staff were able to demonstrate how they accessed all required policies and procedures, which we saw had been kept up-to-date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders clearly recorded any actions that arose from these meetings and shared the actions with staff. Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations. Staff submitted data and notifications to external agencies as required.

Sustainability was monitored by the management and leaders at the practice, and we were provided with documented evidence to show that all aspects of their ability to provide a consistent service to people had been considered.

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.

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