The Bacon Lane 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 inspection in July 2023, we rated this key question as Requires improvement. At this assessment, the rating has changed, and we rated this key question as Good.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice 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 kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Feedback from staff interviews suggested a positive relationship between staff and management, with staff reporting that they enjoy working at the practice.

The practice 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 was approachable and responded to any concerns raised. Staff also told us leaders consistently modelled the values of the practice. We observed that the leadership team actively collaborated with other practices within the Primary Care Network (PCN) and was engaged in the development of primary care services in the local area. For example, the senior partner was delivering diabetes training within the PCN. In addition, the other 2 partners held key leadership roles: one as the Harrow Primary Care Cancer Lead and the other as the PCN GP Educator Lead.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong staff apologised and gave people support. Lessons learned from complaints, significant events were shared with staff during staff meetings and minutes of such meetings shared with all staff electronically. For example, the practice investigated an incident which involved a blood test result being sent to the wrong patient due to an incorrect email being entered in the patient’s record. The practice implemented necessary actions, reminded staff to double check the information and advised staff to share the blood test results via the clinical software.

The practice valued diversity in their workforce. They work 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. We saw examples of how adjustments had been made to enable staff to work effectively at the service. The practice provided training in equality and diversity, and leaders fostered an environment where staff felt confident in their roles and enjoyed their daily responsibilities.

The practice 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. 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 practice installed 22 solar panels and reduced electricity consumption by 36% annually, contributing to environmental sustainability.

They always share information and learning with partners and collaborate for improvement.

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

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. For example, the practice hosted a weekend flu clinic that was attended by over 400 patients. Staff also made adjustments to improve coordination with community healthcare services, including hosting a weekly walk-in clinic every Thursday morning in partnership with the local social prescribing team.

The practice was one of 4 local practices selected to lead a proactive care project targeting patients with obesity, diabetes and early stage cardiac or renal disease. Patients were proactively invited for structured face-to-face reviews and screening. Follow up appointments were held after 3 to 4 weeks to ensure safety monitoring and provide ongoing coaching. At the time of this assessment, over 60 patients had been reviewed through this initiative.

The practice had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 leadership team was committed to upskilling staff. For example, the practice supported a member of the reception team to enrol in the new Trainee Nurse Associate programme.

The practice could demonstrate how it used complaints, incidents and feedback to improve. We observed that the practice had developed and maintained digitised systems for HR records, complaint management, the risk register and the significant event log.

A quality improvement plan was in place to support ongoing service development, and the practice regularly monitored its performance through clinical audits.

The practice demonstrated a forward-thinking approach by investing in multiple software systems to enhance service delivery. For example, in response to feedback from the Patient Participation Group (PPG) and patients, the practice implemented an electronic system to streamline the triage process. This system was also used to communicate with patients, including sharing blood test results.

The practice utilised NHS approved Artificial Intelligence (AI) software to process clinical documents, enabling more consistent coding, improved efficiency, and better workload management.

The practice implemented an electronic system to automate and streamline the new patient registration process, ensuring that all patients were registered within 48 hours.

The practice developed an effective digital governance monitoring system by efficiently utilising a widely available task management software. This allowed for real-time remote oversight and generated automated task reminders to ensure timely compliance.