Northdown and Dashwood 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

Systems were not always embedded to identify, manage and mitigate risks. Some staff did not always understand the full extent of their roles and responsibilities.

However, leaders and staff had a shared vision and culture based on listening, learning and trust. Staff felt supported to give feedback either directly or via colleagues and were treated equally, free from bullying or harassment. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.

We found breaches of regulation in relation to good governance. We have asked the service for an action plan in response to the concerns found at this assessment.

This service scored 57 (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. For example, to ensure the service’s digital strategy was inclusive, they held an engagement event in the local community and invited their patient population to attend. The service told us this resulted in approximately 60% of people registering for the new digital system.

The service had inclusive leaders 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 and experience to lead effectively.

Staff told us their colleagues were approachable,very supportiveand acted with integrity,opennessand honesty. We saw the partners were committed and spoke openly about how they intended toimprove services. The leadership team worked with other practices in the primary care network and were engaged in the development of primary care services in 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 established Freedom to Speak up arrangements in their practice and externally in their primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The service planned to appoint staff representatives to improve communication with staff and had received a positive response from staff members.

Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued and fully able to participate in work. For example, we saw adjustments to support disabled staff were in place. Staff told us the management team listened, supported, and accommodated requests for flexible working.

The service did not have clear responsibilities, roles and systems of accountability and good governance. For example, systems to identify and implement learning from significant events were not embedded. Learning identified was not always consistent in documentation and protocols were not always updated to reflect changes identified. Governance processes to support the analysis and dissemination of learning from incidents were not embedded. The service told us they had not reviewed significant events for 5 months due to conflicting priorities.

Processes to support the identification of people associated with safeguarding concerns were not fully embedded.

The service was unable to demonstrate how they maintained oversight of all clinical practice as they did not have a process of clinical supervision or monitoring for GPs working in the service.

Policies did not always contain necessary information to give guidance to staff. For example, the medicines management policy did not provide detail on escalation processes should people not engage with ongoing monitoring.

However, staff could access all required policies and procedures. Staff took patient confidentiality and information security seriously.

The service actively engaged, collaborated and worked in partnership with neighbouring practices and within their Primary Care Network, to ensure services supported people. The establishment of their care and nursing home team had improved services for frail and elderly people. They had reduced unplanned admissions to hospital and reduced GP clinical time on associated actions increasing clinical capacity in the practice.

The service focused on continuous learning and recognised the need to improve and embed best practice into their operating model. 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.

The practice had a quality improvement plan in place to help drive improvements in service. This included introducing a new digital triage system and AI technology to assist with clinical coding.