Prince Avenue Surgery Also known as Dr Sooriakumaran & Dr Santhakumar

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

At our last assessment in 2015, we rated this key question as Good. At this assessment, the rating remains the same.

People’s care, treatment and support had promoted equality, removed barriers or delays, and protected their rights. Leaders and staff had proactively sought ways to address barriers to improve people’s experience, acted on information about people's experiences and outcomes, and allocated resources and opportunities to achieve equity. Leaders were aware of local and national challenges and had developed a strategy for the future and a succession plan which aligned with this vision

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.

All staff had contributed to the development of the practice vision and strategy, which was regularly reviewed. The practice was aware of the local population demographics and was working with partner agencies to address current and emerging 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, supportive 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 established Freedom to Speak Up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns and felt safe doing so.

The service demonstrated a strong commitment to diversity within its workforce. Leaders actively promoted an inclusive and fair culture, and staff told us they worked well together and supported one another. There were clear processes for raising concerns, including opportunities during meetings, supervision, appraisals, and through confidential staff surveys. All staff had completed equality and diversity training, and policies and procedures were in place to promote diversity and equality. Adjustments had been made to ensure all staff were valued, for example we saw examples of reasonable adjustments to support individual staff were in place.

The practice had clear roles and responsibilities, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared 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 to complete appraisals and performance reviews. The provider demonstrated that appraisals followed a structured process.

The practice had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical and non-clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

Staff took patient confidentiality and information security seriously, supported by relevant policies and procedures.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network to offer extended access, an enhanced range of appointments and vaccination programmes.

Staff from partner organisations spoke positively about the experience of working with the practice.

The service focused on continuous learning, innovation, and improvement across the organisation and local system. We observed evidence of shared learning and staff involvement at all levels. Leaders had regularly reviewed the service’s assurance systems. Clinical audits and quality improvement processes had positively impacted the quality of the service.

The provider had implemented a range of clinical and non-clinical quality improvement protocols to drive service improvements, which included a review of the appointment system.

The provider had implemented a range of quality improvement protocols to drive service improvements, which included a review of the appointment system.

The lead GP was committed to ongoing development and attended many training courses, updates sessions and events to ensure their own personal development. These learning experiences were shared with the wider staff team to improve outcomes for patients.