Ash Trees 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.

This service scored 71 (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.

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.

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. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had a Freedom to Speak Up (FTSU) policy in place. The practice had a designated FTSU guardian that staff could contact if there were any concerns. Managers were also available and receptive to hearing about the concerns staff may have had. The practice promoted a positive and supportive culture where people felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns, contribute ideas and give feedback. Managers had an open-door policy for all staff.

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.

Adjustments had been made to ensure all staff were valued, for example, we saw adjustments to support staff with alternative needs or who worked better in an adapted environment. Managers were positive in identifying where staff’s skills lay and provided opportunities for staff to work to their strengths. We saw multiple examples of staff who were supported to develop in this way and this in turn led to a positive and engaged workforce.

Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff.

The service had clear responsibilities, roles and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on information about risk, performance and outcomes, but documentation of action taken and outcomes was not always completed fully.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. However, appraisals and performance reviews were overdue. The practice was aware of this and were planning to relaunch a new appraisal system and had formulated a recovery strategy. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. However, managers did not always clearly record any actions arising from these meetings and how and when they had been actioned. Minutes were shared with staff, but these were not always sufficient in detail to enable shared 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 provider worked with other practices within their primary care network to offer extended access and access to a range of healthcare resources. The practice had established effective and positive relationships with community services, charities and other healthcare providers.

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 contributed to safe, effective practice and research.

The practice had adopted new initiatives to improve their performance and provide improved access for patients. They had tangible evidence on how the new triage system was positively improving experiences for patients. They were proactive in implementing new projects for vulnerable patients.

The practice had established a research hub with funding and opportunities for research and staff were encouraged to engage with this. The practice had an annual audit programme and projects to drive up quality and performance.