St Mary’s 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 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 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.

Leaders described the ongoing work with the primary care network (PCN), and how one of the leaders is a non-clinical director of PCN and they described an event held in collaboration with Kings Fund health inequalities.

Staff we spoke with 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. Leaders evidenced redevelopment plans to accommodate the need for accessible services for their demographic population.
 

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 we spoke with described a flat management structure and ethos of being open and friendly, and this enabled all leaders in the practice to always be approachable and respond quickly to any concerns raised. Staff told us leaders modelled the values of the practice vision and mission statement, and this was embedded throughout the practice. We saw the leadership team worked closely with other practices in the PCN and were engaged in the design and development of primary care services within the local area.

Clinical staff told us that leaders would accompany them on home visits during vaccine appointments and drive staff to those appointments. Leaders described a culture of people feeling valued and that all staff have an important part to play within the practice and positive feedback from friends and family test are posted on staff board to boost morale and acknowledge the good work that staff do and how much they are appreciated. Staff we spoke with described regular team building events outside of the workplace to promote strong connections throughout the teams and these events were also a way to support local charities.
 

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements with other practices in the PCN. Staff told us they were aware of the process for speaking up and raising concerns and would feel comfortable doing so.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued. Leaders we spoke with described adjustments that had been made to accommodate member of staff requests.

The service 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 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. The provider had established governance processes that were appropriate for their service and there was a business continuity plan in place that all staff were aware how to access.

Systems for identifying, capturing and managing risks, complaints and significant events were effective. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns, significant events, complaints and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff along with outcomes for learning. Staff took patient confidentiality and information security seriously.
 

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 had an active Patient Participation Group (PPG) and evidenced minutes from those meetings.

The provider worked with other practices within their primary care network to offer extended access, and vaccination programmes. Staveley Surgery has 1 community defibrillator that is accessible to the local community 24/7 along with community bookstore locker. The practice reviewed external sources of feedback such as the National Patient Survey and the NHS Friends and Family Test and had implemented changes to the service as a result of feedback.
 

The service 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 contribute to safe, effective practice and research. All staff were encouraged to put forward and test out new ways of working.

Processes were in place to ensure that learning was shared when there were incidents and complaints. We saw significant events were recorded and actioned appropriately as per the provider’s own policy.

The practice had a system of oversight and audit of clinical consultations, record keeping and prescribing for advanced care practitioners. Regular staff meetings took place and contained detail of attendees and agenda topics, including learning and this was shared with staff.

The practice has identified improvements needed for additional clinical space, to meet the needs of elderly population and need for more clinical rooms downstairs and need for extra space to take on more staff. Evidence provided shows that work has started with the Integrated Care Board on plans to develop an extra 3 downstairs clinical rooms.

Evidence of innovative practice relating to health inequalities include attending local farming marts to encourage more farmers within the community to access regular health checks and blood pressure checks were offered at these events. Other areas of health and well-being include initiatives to support the elderly population to remain independent and able to live independently in their own homes.

Work was also underway with a local hotel chain to work collaboratively with hotels to support and encourage the large population of migrant workers within the hospitality industry to register with the Surgery and promote the benefits of regular health checks, screenings and immunisations to encourage good health and reduce pressure on secondary care services.