Hucclecote 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 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 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.

Senior leaders had contributed to the development of the service vision and strategy, which was kept under review. The service was aware of the projected increase in the demands of the local population and was working with partner agencies to address future challenges.

The service was planning a move to purpose-built premises in the future and, at the time of our onsite visit, were in discussions with the local planning department. Detailed plans of the proposed new building were on display in one of the waiting rooms to people to view. Staff told us of the challenges they currently face as they have outgrown the current premise and were looking forward to relocating.

Staff feedback described an open and positive working culture where everyone felt valued and supported. They told us there was a friendly team atmosphere.

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.

Leaders and staff all showed confidence in their service and displayed an openness when engaging in discussions with each other and with external services.

Staff told us leaders in the service were visible, approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. We saw the leadership team worked with other services in the local primary care network and were engaged in the development of primary care services within the local area.

We received 15 staff feedback forms which contained positive feedback demonstrating staff felt leaders were always visible, approachable and compassionate. We also spoke to staff in remote interviews and during the onsite visit who corroborated this. Staff said they were fully supported at work and could raise and discuss personal issues which may impact their performance. Workplace adjustments were tailored to individuals by understanding leaders.

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

The service had established Freedom to Speak up (FTSU) arrangements. The service asked staff who they would feel comfortable raising concerns to and assigned this willing person the role. We spoke to the FTSU champion who told us they would feel confident in raising concerns to the leaders. Staff knew who the FTSU champion was and were aware of how to raise concerns.

Leaders told us there was an open-door policy at the service which was confirmed when we spoke to staff.

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. Reasonable adjustments had been made to ensure all staff were valued. We found examples of where leaders were compassionate and supportive of staff during times personal circumstances may affect their attendance at work.

Staff feedback described an open and positive working environment where staff felt where everyone felt valued and supported. They told us there was a friendly, inclusive team atmosphere.

Staff feedback demonstrated there was a no-blame culture at the service.

The service had clear responsibilities, roles and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support. However, we identified some shortfalls in the oversight of governance. The service acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews. However, competencies, supervisions and appraisals had taken place for some staff but only 1 person in the service had access to the documents we viewed. This meant if this person was unavailable, these documents could not be accessed. Following the onsite visit, the service told us they were going to review their processes to further improve their record keeping.

The service had established governance processes that were appropriate for their service. However, these were not always effective. For example, the low completion rate of training (50-75%) indicated a lack of oversight to ensure staff were completing mandatory training in a timely manner. In relation to recruitment, staff files we reviewed did not contain all the information required in line with the service’s policy. Following the onsite visit, the service immediately addressed our concerns and planned to review all staff files and either obtain any missing information or complete a risk assessment.

The service had not identified the shortfalls we found to ensure medicines were managed safely. For example, our clinical searches identified safety alerts were not always acted upon, and oxygen cylinders were not being stored safely. Following the onsite visit, the service immediately addressed these concerns and mitigated the risks.

People’s records did not always contain information about capacity, consent or planning for the future. The service was already aware of this shortfall and were in the process of reviewing their systems and processes to address this.

However, staff could access all required policies and procedures. Leaders held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Actions arising from these meetings were recorded shared with staff.

Staff took people’s 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 service worked with other services within their local primary care network (PCN) to offer extended access. Staff had made adjustments to improve coordination of their service with community healthcare services, including attending regular frailty meetings centred on the care of those at higher risk of hospital admission.

Feedback from a partner organisation demonstrated the service had a good understanding of the people they support. They appreciated having easily accessible and allocated staff who listened to concerns and felt there was an open and transparent relationship.

The service’s patient participation group (PPG) had fundraised to provide defibrillators (life-saving medical devices for people suffering a cardiac arrest) in the community to support the local population.

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.

A quality improvement plan was in place to help drive improvements in services. This focussed on the appointment system.

The service was a training practice supporting doctors to train to become fully registered GPs. One of these GP trainees had completed an audit relating to people prescribed finasteride (a medicine used primarily to treat an enlarged prostate). The audit was used as a basis to develop a new scoring system which indicated when someone may be offered a planned medicine break or may require referral to urology. This led to the innovative scoring system being shared with clinicians across the service to support improvements in care and treatment for people prescribed finasteride.

The service was also an active participation in the local primacy care network (a group of services that work together to collaborate, share and develop new ways of working). The PCN was using Brave AI, a risk stratification computer algorithm to help to identify and review people’s records and assess risks of unplanned hospital admissions. Action would be taken if necessary to try and prevent these unplanned hospital admissions such as a telephone call or visit from the frailty team, a GP appointment offered or a medication review.