Colliers Wood 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.

The senior managers meet every week to discuss all areas of the practice ranging from staffing issues, future developments, incidents, safeguarding and generally sharing good practice. The practice manager told us this meeting was useful in providing information to have good oversight of the practice.

We reviewed staff meeting minutes and saw that they had processes in place to ensure all staff had opportunities to contribute to the development of the practice vision and strategy.

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.

Leaders told us that they meet on a weekly basis formally and informally in-between if required. They said these weekly meetings were central to the way the practice was run as they discussed all issues from clinical to practical day to day matters. Leaders said to ensure staff were supported they ensured that a partner GP was always on-site.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff referred to managers having an “open door” policy and they felt confident to go to them if they needed support and advice.

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 fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network and had an appointed Freedom to Speak up guardian from a partner practice. Staff were aware of how to raise concerns and told us they would be confident in raising a concern if they needed to.

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. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

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. For example, staff were clear on which manager to go to for specific matters. The deputy practice manager met with staff to complete appraisals and the GP’s carried out appraisals and development meetings for clinical staff.

The provider had established governance processes that were appropriate for their service. Staff told us they could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. We saw meeting minutes confirming this. 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 share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer services. Staff had systems to work with community healthcare services, which included meeting with them regularly to discuss service provision and improvements.

The practice was in the process of re-establishing their patient participation group.

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. They actively contribute to safe, effective practice and research.

Leaders told us that they had clinicians who had expertise in areas such as MSK (musculoskeletal), and ENT (ear nose and throat) and they used these skills to develop staff and colleagues in other practices.

All staff were encouraged to put forward and test out new ways of working to improve. For example, they had introduced remote monitoring of fridge temperatures with an app. The app was downloaded on staff phones, and they were able to see if temperatures fluctuated outside of range if they were off site. The practice manager told us that it had helped to identify a time when the temperature was out of range and they called the practice immediately to let staff know.