Lakeside Medical Practice

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, we rated this key question as outstanding. At this assessment, the rating has changed to good. At this inspection we found that some of those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. While the provider had maintained this good practice, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing well-led services.

Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities.

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 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 was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice.

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. This included 2 Freedom to Speak up champions, one internally and one external to the practice. There were also arrangements specifically for GP trainees to raise concerns. Staff were aware of how to raise concerns and we saw details of the Freedom to Speak up arrangements were on posters throughout the practice.

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.

At the time of our inspection the practice did not have a registered manager. However, we saw attempts had been made by leaders at the practice to resolve this, and there was a plan to have a registered manager in place as soon as the correct documentation for this was obtained. The leadership structure consisted of 5 GP partners. We saw evidence of clear responsibilities, roles, systems of accountability and good governance within this structure. Leaders acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on the individual roles and responsibilities within the practice. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Staff took patient confidentiality and information security seriously.

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

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. However we found that some opportunities for learning were sometimes missed due to lack of reporting on significant events and sharing of learning from significant events and complaints.

The service demonstrated areas of innovation, including the development of efficient processes for managing results and correspondence. The provider had made changes to the appointment triage system so that all requests were triaged by clinicians. There was no limit on the appointments offered throughout the day to ensure patients could access care in a timely manner. There was a strong focus on working with the local community to understand health inequalities and provide accessible care.

There was a patient participation group (PPG) at the practice. The group had recently had their first meeting. There was information on the practice website encouraging patients to join the group.

Staff shared examples of changes made as a result of patient feedback. For example, the layout of the practice website was changed to make the appointment request form easier to find.