Sandy Lane 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 meant the service was managed and well-led. Leaders were very compassionate and inclusive, and staff felt supported and valued. The culture they created promoted high-quality, person-centred care.

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.

There was a clear mission statement, which was displayed within the practice. The service’s vision showed aspirations to provide the highest possible standard of professional interaction with people, staff and wider community. The service committed to provide high quality and accessible healthcare and to treat people with courtesy and respect and strive to develop the practice to be a leader within the community.

Staff were positive about the culture within the service and described it as open, transparent and supportive.

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 always did so with integrity, openness and honesty. This was echoed by staff who spoke positively about the leadership, who stated that the managers were approachable and responded to any concerns raised.

The service held regular management and staff meetings to ensure all staff members were aware of changes to service delivery. This was supported by notice boards communicating changes to all staff members.

The service had an equality and diversity policy and promoted equity to all people, including staff, with diverse needs and protected characteristics, such as sexuality (LGBTQIA+) age, religions, disability, race. Staff told us that leaders cared about their wellbeing and they felt supported.

Representatives from the Patient Participation Group (PPG) told us they felt the provider was open to constructive challenge and proactively made improvements to the service. The PPG member we interviewed informed us that complaints and significant events were a standing item on the PPG agenda. The PPG member described the group as the service’s “critical friend.”

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

There were systems in place to support staff to whistle blow or to speak with a Freedom to Speak Up Guardian if they had any concerns. Staff were aware of how to whistle blow and who the Freedom to Speak Up Guardian was and what their role was in supporting staff. The practice had established Freedom to Speak up arrangements with the Integrated Care Board.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and governance which they used to manage and deliver good quality, sustainable care, treatment and support. They acted on information about risk, performance and outcomes.

The service demonstrated organisational skills by having tools to monitor all aspects of the management of the service. For example, diary dates were in place for monitoring staff training with diarised reminders sent to staff members and the manager before training became overdue.

Managers held regular clinical meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded actions arising from these meetings and shared these with staff.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Processes were in place for appraisals and performance reviews for all staff. Staff knew how to access all required policies and procedures.

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.

There were processes in place to work in partnership with key organisations and agencies to support the provision of care and joined up working. Staff told us they regularly went over and above for people by referring them to services within the community such as a health and wellbeing coach to support them to live healthier lives.

The service focused on continuous learning, innovation and improvement across the organisation and local system.

Regular de-briefs were held with the pharmacist to monitor the prescribing of medicines and people were seen with the oversight of the service’s GPs.

The service used learning from patient feedback, significant events and complaints to continually improve the service they provided, and changes were made within the practice if needed.