Pitsmoor Surgery

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• 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

The practice had a clear vision and credible strategy to provide high quality, person- centred care although improvement was required in equity of access to an appointment and by telephone. There were positive staff cultures with all staff reporting that they felt supported by the GPs and management. Governance structures and systems were in place although some required review. For example, policies did not always reflect what was happening in the practice and improvement to some monitoring systems was required, for example, monitoring of patients on some high risk medicines and taking action to monitor undiagnosed conditions. There was compassionate, inclusive and effective leadership at all levels and the provider had reviewed different ways to support their practice population, particularly around uptake of childhood immunisations and cervical cytology uptake. There was evidence of systems and processes for learning and continuous improvement.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders we spoke with had a shared vision and strategy to provide patients with high quality care. They told us there were some vacancies in the clinical team and adverts for recruitment for a full-time practice nurse and a salaried GP were in progress with a further salaried GP due to commence imminently. Leaders had attended a meeting in February to review their business strategy. They told us that they hadn’t discussed the full business strategy with staff but had discussed themes from this with them at team meetings, for example, access, staffing levels. Staff told us that there was a positive team culture within the practice and that they felt supported by managers and the GPs. Staff reported that they felt able to raise concerns with leaders without fear of retribution and they knew how to access the whistleblowing policy.

The provider had a business plan and a business recovery plan in place. They had completed a quality improvement audit on access as they were aware of patient feedback. However, at the time of the site visit patients’ still continued to feedback that they struggled to access an appointment. Staff attended regular team meetings including clinical meetings. Records of these were available to staff on the practice’s computer system. The practice had a whistleblowing policy and there were systems to ensure compliance with the requirements of the duty of candour in place.

Staff told us they could approach leaders and the GPs at any time if they required support and that they had received regular appraisals. Two staff were overdue their appraisal and the patient services manager had a plan to address this. All staff reported that they had received the training they required for their role, including those with lead roles, for example, the infection, prevention and control lead. Staff said they felt supported.

Appropriate recruitment checks were completed for staff. We reviewed 3 personnel files and found appropriate checks had taken place including disclosure and barring (DBS) checks and induction records were completed for new staff. The majority of staff were up to date with their training or had a date scheduled for it.

Staff reported they were aware of how to access the whistleblowing policy and details of the Freedom to speak up arrangements.

The provider had appropriate policies and procedures in place to support staff who wished to speak up and the whistleblowing policy included independent contacts to whom staff could raise any concerns.

Staff told us they felt supported and able to raise concerns and felt they were treated with care and concern. Staff with lead roles were given time to carry out their duties. The provider told us staff wellbeing was important to them. A staff wellbeing survey had been carried out and a staff newsletter introduced which included a positivity corner and external information, for example, waiting list times and referral routes. Clinical supervision was taking place. However, this was informal and leaders told us this would be formalised moving forward.

Appropriate recruitment processes were in place and staff had received regular training updates and the premises were physically accessible for patients.

Staff knew how to access practice policies and they attended regular meetings. Staff felt there was positive team culture.

There were effective arrangements for identifying, managing, and mitigating health and safety risks. However, Some oversight arrangements required review, for example, oversight of practice policies and staff appraisals, recording and formalising clinical supervision, systems to monitor blank prescriptions and timely action of medicine alerts. There were clear arrangements in place for the availability, integrity and confidentiality of data, records and data management systems. There was a suite of policies accessible to staff on the practice’s computer system including a business continuity plan, although we observed some did not correlate with what staff were doing or included inaccurate information or were generic. We saw evidence these were updated immediately following the site visit. 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. The provider reviewed, evaluated and audited the service provided.

The provider had collaborated with a local hospital to offer some weekend events at one of the practices within their primary care network aimed at engaging with their Roma community about health and social issues which included drop-in immunisation clinics.

Leaders told us they worked with their primary care network to deliver services for patients, for example, the social prescribing and immunisation drop-in clinics and had worked with a local university to set up a focus group with Roma, Somali and Yemeni communities to explore health literacy and where communities access their health information and what they consider to be trusted sources of information. Leaders told us this learning had been shared widely across the city with other organisations.

Staff told us they attended MDT meetings with district nurses and health visitors and that the GPs had good relationships with the providers of care homes that they provided care to.

Leaders attended regular primary care network meetings to discuss ways they could implement more coordinated and integrated health and social care for people within their community.

The practice had lead GPs allocated to the care homes that they provided care to. They held regular MDT meetings where patients who may be vulnerable were discussed. Succession planning had been discussed and action was being taken to address staff vacancies.

Staff told us they had received the training and support they required to do their role and were supported with their development. For example, a practice nurse had been supported with the advanced nurse practitioner course. Incidents and complaints were discussed at clinical meetings and any learning shared with staff. A GP partner had written a published paper on the work the practice had carried out for patients with severe enduring mental illness to share experiences with other providers.

Clinical audits and nurse led audits were used to drive improvement. The provider had a process for monitoring complaints and incidents to review any themes and trends. The provider had reviewed different ways to support their practice population, particularly around uptake of childhood immunisations and cervical cytology uptake. The provider is a teaching practice for GP registrars and a training practice for qualified nurses new to general practice. They have also supported other staff to develop, for example, they have supported 2 practice pharmacists with their prescribing qualification.