Lee Road 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 and fair culture.

At our last inspection, we rated this key question as good. At this inspection, the rating remains the same.

Leaders were visible, knowledgeable, and supportive. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. There was a culture of 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.

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.

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 concerns raised.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established external Freedom to Speak Up arrangements, as well as designated internal staff members who could be approached for support. Staff told us they felt comfortable raising concerns with members of the leadership team.

Policies and procedures to promote diversity and equality were in place. Staff had completed equality and diversity training. Adjustments had been made to ensure all staff were valued.

There were clear responsibilities, roles, and systems of accountability. Staff told us they felt proud to work in a practice that cared about staff and patients. We found improvements were required in relation to the governance, oversight and management of risks relating to; patients with long-term conditions; review of patients’ treatment; and safeguarding processes. Following our inspection the provider took immediate steps to address these risks. The provider also submitted an action plan detailing how they planned to continue to monitor and identify risk in the future.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners. There was an active patient participation group (PPG). Patients told us they found the practice listened to the views of the PPG and took action. There were adverts in the practice waiting room and signup forms on the practice website for patients wishing to join the PPG.

The service focused on continuous learning, innovation, and improvement across the organisation. The provider encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. The practice had a quality improvement plan in place. Patients gave examples of where concerns had been raised with practice staff. Patients saw their concerns were reviewed and saw improvements in the service as a result.