Streatfield 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 has changed.

At this assessment we found the service in breach of legal regulation in relation to Regulation 17 – Good governance.

This service scored 62 (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 Caring, Quality, Respect, Access and Working together. The practice focused on providing a caring, safe, and high-quality healthcare for their community. Their goal was to support the health and wellbeing of patients with respect, compassion, and trust.

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. All staff we spoke with said they did so with openness and honesty. Staff also we spoke with also said that the leaders were very supportive. All staff had received appropriate appraisals.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns. Staff were aware of who to speak with internally as well as externally if they wanted to raise concerns.

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. The practice was committed to fair and equitable treatment of all staff, respecting human rights and promoting workforce diversity. Flexible working arrangements were supported, with adjustments made to accommodate staff with health needs and childcare responsibilities. The practice had a range of well-being initiatives, including a practice walking club, meditation sessions and staff outings. The practice monitored gender pay gap and worked towards the Workforce Disability Equality Standard (WDES) and Workforce Race Equality Standard (WRES) in order to identify and address any inequalities.

The practice had responsibilities, roles, systems of accountability and areas of 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 shared this securely with others when appropriate. Leaders and managers supported staff, and all staff we spoke with during the assessment were clear on their individual roles and responsibilities. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. We saw that the practice clearly recorded any actions arising from these meetings and ensured they shared these with staff.

However, we did find some areas for improvement. During our on-site visit, we found gaps in training files. There was a shortfall in the oversight of staff recruitment records. There were no audits or systems in place to identify gaps in training and recruitment files. Recruitment files were demonstrated to be in place following the on-site visit. The service, after the on-site inspection, provided evidence staff were up to date with their required training. We also found that some records we reviewed for adults, with children about whom there were safeguarding concerns, did not have a code to highlight this on the records system. The practice demonstrated that they had followed up and taken appropriate actions on our findings.

During our clinical searches we found that some medication reviews did not identify risks involved to patients. We also found some medication reviews were recorded on the system but had no details or information recorded within them.

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. The practice was a part of Sphere Primary Care Network (PCN). The practice had collaborated with Sphere PCN on several initiatives including schemes focused on obesity, a cycle hub project, a local disability scheme and they had partnered with the local Citizen's Advice Bureau to house one of their staff members in Sphere PCN practices. The practice supported a residential care home, providing weekly visits led by the practice pharmacist with support from a lead GP. The care home had bypass numbers for the practice as well as contact details of lead clinicians.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They actively contributed to safe and effective practice and research. The practice had a quality improvement plan in place to help drive improvements in services and we saw various audits to demonstrate this. This included a telephone access audit and a DNA (Did Not Attend) Audit. The DNA audit showed higher DNA rates among younger patients and for morning appointments. In response to this, the practice introduced text reminders and clearer cancellation options, which led to a reduction in DNAs on re-audit.