Newhall 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 has changed to good.

This service scored 68 (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. The mission statement was ‘For excellent individual care at all stages of life’. The vision for the service was ‘To improve the services we provide to our patients continuously by ensuring easy access to a safe, well-led and effective service’. Staff told us the leaders were forwarding thinking with a desire to put people at the centre to the care.

Feedback we received from the majority of staff regarding the culture within the service was positive. They told us it was a friendly and supportive environment to work in and they enjoyed working there.

The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges. The leaders had worked with the local Integrated Care Board and local council and there were plans to build a new GP surgery within the new housing development. The leaders had shared these plans with staff so they understood the future direction of the service.

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.

The service had a stable and experienced leadership team. The majority of staff spoke positively about the leaders, that they were approachable and responded to any concerns raised. Staff told us leaders held regular ‘open door’ sessions but they were also accessible at any time. 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 aimed to foster a positive culture where people felt they could speak up and their voice would be heard. There were systems in place to support staff to whistle blow if they had any concerns. The service did not have a designated Freedom to Speak Up Champion and staff were not aware if they had access to an external Freedom to Speak Up Guardian. However, information about the external Freedom to Speak up Guardian and their contact details was on display around the building. The majority of staff felt that they could speak up and most felt that their voice would be heard and acted upon.

The service 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 senior leaders had addressed concerns related to discrimination. The service had introduced a development framework for staff, which provided a structure for development and promotion within staff teams. Adjustments had been made to ensure all staff were valued. Staff shared examples of adjustments that had be implemented to support them in the workplace.

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 acted 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. 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.

Although staff could access all required policies and procedures a number required updating to ensure the information was up to date and accurate. Following our assessment, the provider sent us the updated policies.

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. Staff were encouraged and supported to attend local forums which provided networking opportunities with other services within the primary care network. These included monthly practice manager meetings. The provider worked with other practices within their primary care network to offer enhanced access, and flu vaccination programmes.

The service had a patient participation group (PPG) which was supportive of the service in driving improvements. The PPG was supporting the service with the introduction of the new online booking and triage system.

The service was proactively developing the service it provided for the transgender community and was working towards accreditation for Pride in Practice. Two GPs had engaged with a local gender identity clinic and arrangements had been made for a local support group to come to speak with staff about positive engagement with transpeople. The service accepted out of area people with gender dysphoria and supported shared care agreements.

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.

The service was a well-established training practice for GP trainees and medical students. Systems were in place to support trainees and students during their placements. The service used learning from significant events and complaints to continually improve the service they provided.

Staff participated in quality improvement work and the findings were shared across all staff teams.

Following feedback from people the service had introduced an appointment booking and triage tool, to improve equity in access to appointments.