Cambrian 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 Good. At this assessment, the rating remains the same.

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.

Staff told us that they had come together to reflect on the successes and changes of the previous year and had plans in place to have a working group to set core strategies for continuous improvement.

All staff had contributed to the development of the practice vision, which was to be resilient and deliver exceptional healthcare through teamwork and innovation. We saw clear evidence that the practice applied their values during their work, which included being caring, responsible, trustworthy and responsible.

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 any concerns raised. Staff described the practice as a friendly, supportive, and well-led workplace with strong teamwork and approachable leadership. They felt valued, appreciated, and committed to delivering high-quality patient care despite rising demand.

We saw the leadership team worked with other practices in the Primary Care Network (PCN) and were highly 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 recently appointed a new Freedom to Speak Up lead and staff also had access to a freedom to speak up guardian outside of the practice. Staff were aware of how to raise concerns and told us they were comfortable in doing so. Staff described an open and learning culture and a positive team morale and collaborative culture.

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 and were readily accessible within the staff handbook. Staff told us that adjustments had been made to support them undertake their work and that the practice offered flexibility where able. Partners confirmed that staff were trained in equality and diversity, which reflected information held on the practice training matrix.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share 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. Staff were aware of those who held key roles within the practice, and these were clearly displayed on notice boards and within a skills matrix document.

Managers met with staff regularly to complete appraisals and performance reviews. The provider 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 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.

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 collaborate for improvement.

The provider worked with other practices within their primary care network (PCN). Examples of this work included introducing the Cancer Care Coordinator role and being involved in creating the model that was introduced to practices within the PCN and wider network. The practice also supported this role by hosting meetings to share best practice among the Cancer Care Coordinators. Other projects included preventative work for the early detection and intervention of atrial fibrillation (AF). One of the partners was a Clinical Director for the PCN.

Staff had made adjustments to improve coordination of their service with community healthcare services, for example, the cancer leads met at the local hospices to discuss care and treatment.

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. As a training practice, they offered supervision of trainee doctors and placements for health professionals, including nurses. The practice had a quality improvement plan in place to help drive improvements in services. There was anopen culture within the practice which involved staff in regular discussions about priority areas for improvement. One of the priority areas identified was the introduction of total triage and workflow with the aim of improving access. All staff were encouraged to put forward and test out new ways of working. We saw examples of learning from significant events and complaints.

The practice had engaged in research, including randomised controlled trials, observational studies, and longitudinal research. This had enabled the practice to offer valuable research opportunities directly to patients within the surgery. One of the partners was taking part in a trial focusing on patients aged 75 and over evaluating the effects of de-prescribing medications, that potentially contributed to falls among frail elderly individuals.

Another planned research specifically focused on individuals of Pakistani or Bangladeshi heritage, including those born in the UK, to better understand genetic influences on health within these communities.