Drs T A Underwood & M A Thompson

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

Leaders and staff had a shared vision and culture based on listening, learning and trust. 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. There was a strong culture of continuous improvement and innovation with staff given time and resources to try new ideas.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were a shared vision, strategy and culture. The provider’s strategic priorities were explicitly aligned to local population needs. There were clearly identified priorities with named leads and deputies for continuity. The key priorities included diabetes/ metabolic health, and physical health care for people with severe mental illness (SMI).

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Staff we spoke to were motivated and consistently felt well-supported by leaders. Staff feedback we received suggested they felt valued, motivated and leaders listened and recognised their work. Managers were approachable and promoted new ideas and improvements.

Leaders and staff spoke passionately about improving long-term outcomes for people with diabetes and demonstrated sustained commitment to this work.

They 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.

Staff told us leaders in the practice were approachable and responded to any concerns raised.

Staff reported they had regular meetings and engagement with their managers to keep them informed and involved in this service delivery changes.

Succession planning was well established. Processes were in place to identify staff approaching retirement and support others with leadership potential. Development opportunities and career goals were regularly discussed between staff and their line managers.

We saw the leadership team worked with one other practices in the primary care network and were engaged in the development of primary care services within the local area.

The provider 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 within the Integrated care board (ICB) and internally within the practice. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

Staff told us that managers supported them to raise concerns and viewed this as an important part of maintaining a positive culture. However, some staff highlighted need for clearer reassurance and reinforcement of practice’s speaking up arrangements. The provider was receptive to this feedback and had identified actions to reinforce speaking up arrangements by providing clear reassurance to staff including reiterating routes of raising concerns. We were told these messages will be embedded through team meetings and ongoing communication.

Leaders valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff contributed their views through regular pulse surveys, which covered culture, openness and wellbeing. Feedback from these alongside informal engagement channel were used to inform improvements.

Policies and procedures to promote diversity and equality were in place. All staff had completed their mandatory equality and diversity training. We noted there was diverse workforce working across the clinical, administrative and management roles, reflecting range of ethic and cultural backgrounds.

There was evidence of internal career progression and development opportunities across staff at the practice.

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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly; however, we noted some staff at the practice did not have documented annual appraisals and performance reviews. The practice acknowledged and confirmed that changes were being made to the performance and appraisal model to ensure all staff received regular documented appraisal going forward.

The provider had established governance processes that were appropriate for their service. However, some governance processes needed strengthening. For example, staff immunisation records were incomplete for a few staff but were addressed promptly.

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 clinical leads held regular multidisciplinary (MDT) team meetings with community practitioners, palliative care nurses and safeguarding leads.

Staff and leaders worked in partnership with key organisations to support care provision and service development. Volunteers and universities were actively used to extend capacity.

The practice had continued recruitment activity for PPG and was working to rebuild participation. A PPG meeting had taken place recently with 3 patient representatives in attendance. We noted that the practice also sought to engage patients through other channels, including newsletters, social media and digital updates regarding service changes.

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

The practice actively contributed to the PCN working with the GP partner representation in the Berkshire West PCN alliance.

The provider had a quality improvement plan in place to help drive improvements at two sites. The partners told us the practice strategy prioritised patient safety, health inequalities and staff wellbeing over service growth. All staff were encouraged to put forward and test out new ways of working.

The practice demonstrated a strong commitment to preventative care for patients living with diabetes. For several years, the practice independently developed and funded a structured diabetes support programme, supported by an online platform, which aimed to help patients improve glycaemic control through education, lifestyle support and close clinical monitoring. The ‘diabetes second chance’ diabetes reversal programme focused on type 2 diabetes and metabolic risk and had achieved approximately 12% diabetes reversal compared with national averages of around 4 to 5%.

The provider recently undertook a quality improvement programme to address sub optimal diabetes outcomes. The structured Healthcare Assistant (HCA) led diabetes recall system along with dedicated nurse leadership had resulted in an increase in the diabetes register from 718 to 800 patients.

Social prescribing was fully embedded within the MDT to address social factors of health. The social prescriber had linked patients to 227 community resources supporting access, engagement and health outcomes in the last 4 months.