Somerford Grove Practice

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• 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 practice 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 71 (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 based on inclusion, equality and high-quality patient care. Leaders operated an open‑door approach and were described by staff as approachable and supportive. Staff described a cohesive and supportive working environment where concerns could be raised freely. Staff also told us leaders modelled the values of the practice. Regular meetings, well-being activities, educational sessions and team discussions promoted engagement and shared ownership of the practice vision. The practice's vision included commitments to anti-racism, staff development and environmental sustainability.

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.

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 practice fostered a culture where staff felt able to speak up and raise concerns. The practice manager acted as the Freedom to Speak Up Guardian. Staff told us concerns and uncertainties could be raised openly, and leaders encouraged honest discussion and feedback.

The practice had established an external Freedom to Speak Up Guardian with another practice in the primary care network and had implemented a whistleblowing policy.

Leaders 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. The practice demonstrated a strong commitment to equality, diversity and inclusion through a programme of anti-racism, allyship and reflective learning initiatives. Staff participated in workshops and educational sessions exploring unconscious bias, privilege, power, cultural competence and anti-racist practice. The practice also contributed to wider system initiatives, including work relating to anti-racist healthcare, learning disability health checks and reducing health inequalities. Leaders used these programmes to encourage reflection, improve understanding of the diverse needs of the local population and support more equitable healthcare delivery.

A trained mediator within the practice provided additional support for resolving concerns where required.

The practice had clear responsibilities, roles and systems of accountability. Governance arrangements supported oversight of quality, risk and performance, and regular clinical and operational meetings were used to review emerging issues and discuss service delivery. Quality improvement activity was evident, including prescribing audits that demonstrated reductions in co‑amoxiclav use. Staff understood leadership roles and accountability structures and could access all required policies and procedures.

The practice understood the importance of partnership working and collaboration. The practice worked closely with Primary Care Network colleagues, community teams and voluntary sector organisations. Community engagement included a range of volunteer groups and health initiatives designed to support local needs and reduce health inequalities. The patient participation group also contributed to service development and quality improvement.

Collaboration within the Primary Care Network supported service development and access improvement. Effective working relationships were maintained with neighbouring services, including the use of Additional Roles Reimbursement Scheme staff to enhance patient access.

Staff had made adjustments to improve coordination of their practice with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

Additionally, one of the practice’s partners demonstrated innovation and partnership working in the management of patients with diabetes through the development of an integrated diabetes care plan template. The template automatically populated key clinical information, including blood glucose control, cholesterol, kidney function, blood pressure, weight and screening results, which helped clinicians complete comprehensive annual reviews and ensured areas requiring improvement were addressed consistently. A personalised care plan was generated following each review and was printed or sent electronically to patients. The practice reported that the template improved the consistency and structure of diabetes reviews, helped patients better understand and monitor their results, and encouraged greater self-management. It also reduced the need for additional appointments where results were satisfactory and enabled patients to access relevant services directly, such as retinal screening and podiatry. The innovation was shared across the wider Primary Care Network to support improvements in diabetes care beyond the practice.

The practice demonstrated a clear commitment to continuous learning and improvement. Leaders regularly reviewed assurance systems, clinical audits and quality improvement activity, and staff were engaged in shared learning across the organisation.

The practice also contributed to wider determinants of health through its Green Impact and People and Planet programmes, recognising the links between environmental factors, deprivation and health inequalities. Staff received training on environmental sustainability and health inequalities and were encouraged to identify opportunities to improve patient outcomes and environmental sustainability. This supported the practice’s wider work to reduce health inequalities and improve equity for its local population.