Grayshott 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.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating remains the same.

This service scored 62 (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 understood the needs of the local population and was working with partner agencies such as the Primary Care Network (PCN) and charitable organisations to address current and future challenges. The service had clearly set out its patient charter, mission statement, and 5-year strategic objectives.

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 did not always have the skills, knowledge or experience to lead effectively. For example, lack of management oversight of some incidents and a failure to identify themes and learning and a failure to complete risk assessments to mitigate potential risks. Staff we spoke with told us that they had been given opportunities to take on additional responsibilities. However, we found there was not always sufficient management oversight to ensure they were managing these responsibilities appropriately. Staff told us leaders in the service were approachable, responded to any concerns raised and modelled the values of the service. Staff also described examples of where they felt that leaders in the service had provided compassionate support both professionally and personally. Regular team meetings and discussions were held, including multidisciplinary team meetings, and staff group meetings. Staff told us leaders listened to their feedback and they shared some examples where changes had been made. We saw the leadership team worked with other GP practices in the PCN 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. There were processes for staff to speak up, including through regular meetings and ad hoc discussions. There was a freedom to speak up policy which provided appropriate guidance for staff and contact details of the Freedom to Speak Up Guardian. 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 work for them. Policies and procedures to promote diversity and equality were in place. There were systems and processes to support the workforce, including human resource support. Training in equality and diversity was part of the staff induction. Adjustments had been made to ensure all staff were supported and valued, for example we saw individual adjustments were in place to support staff where appropriate.

The service did not always have clear systems of accountability or good governance. Systems did not always work as intended and leaders therefore did not always act upon or have access to, the best information about risk, performance and outcomes.

Staff described a clear understanding of their roles and responsibilities and those of others. Staff told us the service provided a friendly and supportive environment to work in and that managers and GPs were visible and approachable.

However, we found systems and processes to support good governance did not always work as intended. There was a lack of management oversight of the current risks in some areas which the provider had failed to identify. For example, incident review and recording processes were not operating as intended to ensure sufficient oversight of all incidents and to promote the safety of staff and patients; complaints were not always captured centrally in a timely manner to ensure management oversight; there was a lack of processes in place to ensure that all staff, including those who worked on a sessional basis, were subject to all appropriate recruitment checks and monitoring; there was insufficient oversight of health and safety processes and a failure to identify when they were not operating as intended; premises risk assessment processes were not always fully reviewed or actioned; systems for ensuring staff had access to annual appraisals in line with the provider’s policy did not always work effectively. We were also not assured that all complaints were captured centrally in a timely manner to ensure management oversight.

Processes to monitor the completion of staff training required by the service were much improved since our last assessment. However, those monitoring processes did not extend to locum or PCN employed staff.

Staff could access all required policies and procedures. However, policies and procedures did not always reflect current practice or guidance for staff to follow. Policy review processes were not always clear or accurately recorded.

The service had failed to identify through its own internal governance processes, that it had not fulfilled its responsibility in notifying CQC when there was a change, event or incident in the service.

The service had failed to notify CQC of changes to members of their GP partnership, the names of whom form a condition of their CQC registration. The service had failed to provide CQC with an accurate, up-to-date statement of purpose.

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

For example, at the time of our assessment, the service provided care to approximately 500 people living in care, nursing and supported living homes. They had worked in conjunction with other services in the PCN to develop and implement a care homes support project, with the intention of improving relationships with those care home providers and promoting improved care outcomes for residents. The project involved the development of a dedicated team which included a nurse prescriber and a care coordinator who provided same day support to the homes and the management of long-term conditions.

The service led Collaborative Health Hub events, which were the first of its kind led by a GP practice in the local area, bringing together healthcare providers and community groups to promote a positive approach to healthcare and wellbeing. These events resulted in positive impacts to people who used the service and to some community groups, such as the local allotments providing surplus food to the local foodbank. Since the success of the Collaborative Health Hub events, run by the provider, other local GP practices have run similar events.

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. However, we found some of the systems and processes within the service were not operating effectively to identify, record and manage learning opportunities.

The service had worked effectively to implement a total triage system to improve access to care for patients, with minimal disruption to staff and patients. Staff described positive outcomes for the service and for patients since its implementation. The service had reviewed the implementation and impact of the total triage system and found that total triage had demonstrated positive impact for most patients and staff, with all staff who responded indicating they would not want to move back to the previous appointment system.

The service worked with other GP practices in the PCN to deliver innovative improvement projects to the local patient population. For example, a paramedic home visiting service to provide a quick response to urgent requests for home visits from frail, housebound residents and care home residents. This led to a reduction in response time, better clinical outcomes and a reduction in accident and emergency attendances. The culture of the service focused upon community engagement and being central to community life.