Tudor Lodge 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 practice 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 good.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. The practice had shared their experience of their well-established access model with other local practices to demonstrate how well it worked.

This service scored 82 (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 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.

Staff feedback described an open and positive working environment where staff felt where everyone felt valued and supported. They told us there was a friendly team atmosphere.

Leaders contributed to the development of the practice vision and strategy, which was kept under review. Not all staff we spoke to were aware of the vision and strategy of the service.

The practice 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.

Leaders and staff all showed confidence in their practice and displayed an openness when engaging in discussions.

Staff told us leaders at the practice were always approachable and responded to any concerns they raised. The leadership team worked with other practices and stakeholders and were engaged in the development and progression of primary care services within the local area.

We received 25 staff feedback forms which contained overwhelmingly positive feedback from staff demonstrating they felt leaders were always visible, approachable and compassionate. we also spoke to staff in remote interviews and during the site visit. They told us they felt really included, appreciated and valued. Staff said they were fully supported at work and could raise and discussion personal issues which may impact their performance. Workplace adjustments were tailored to individuals by compassionate leaders.

The practice had fostered 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 the Local Medical Committee.

Leaders told us there was an open-door policy at the practice which was corroborated when we spoke to staff. Staff were aware of how to raise concerns.

The practice valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

There were policies and procedures to promote diversity and equality. Reasonable adjustments had been made to ensure all staff were valued, for example staff told us they were supported to gradually return to work after a period of ill-health.

Staff feedback demonstrated there was a no-blame culture at the practice. They told us they felt they had equal status at the practice, and the staff team was non-hierarchical.

The practice 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 act 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. Not all staff had received an appraisal within the last 12 months; however, the practice told us they plan to monitor this on a monthly basis to ensure they are being completed at appropriate intervals in the future.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Leaders held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Actions 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 work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Feedback from a partner organisation demonstrated the practice had a good understanding of the patients they support. They appreciated having easily accessible allocated staff who listened to concerns and felt there was an open and transparent relationship.

The practice worked with other services within their primary care network to share good practice and improve the local primacy care offering. The practice had shared their experience of their well-established access model with other local practices to demonstrate how well it worked.

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 contribute to safe, effective practice and research.

The practice was an active participation in a local GP federation (a group of practice that work together to collaborate, share and develop new ways of working). The practice was piloting risk stratification software developed by the GP federation which will support continuity of care for patients. This software will be rolled out across the GP federation later this year and the practice had volunteered test the system prior to a wider roll out of the software.

The practice regularly updated a ‘score card’ to continually review and monitor progress on patient safety. This included ensuring people prescribed specific medicines received monitoring or a review at the recommended intervals in line with guidance. This enabled the service to have a clear oversight of patient safety and swiftly address any areas of concern.

The practice had a quality improvement plan in place to help drive improvements in services. This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working. For example, the practice employed an advanced menopause specialist nurse who was able to prescribe certain hormone replacement therapy (HRT). This meant people could access specific HRT medicines without having to be referred to secondary care menopause services with long waiting lists.