Norfolk Street 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

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. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement 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.

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.

Staff who had been at the practice some time recalled being involved with and contributing to the development of the practice vision and strategy. Recently recruited staff were less aware. The practice statement was formed from the acronym CARE,

• C – Compassionate care for every individual
• A – Accessibility to services for all, recognising and respecting the needs of our diverse patient population
• R – Responsive to patient and staff needs
• E – Effective in delivering safe, high-quality healthcare

This statement was displayed in the reception area and on the shared electronic system. There were several staff we spoke with who were unaware of the vision or strategy which we fed back to the service to action.

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

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 were approachable and responded to any concerns raised. Staff spoken with who had awareness of the practice’s values and vision also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

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 which included those with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The service strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. We saw senior leaders would address concerns related to discrimination. The service had a diverse staff team with clear awareness of local demographic patient needs. The leadership team authorised flexible working requests for both clinical and non-clinical staff and were responsive to any changes to working as a result of staff disabilities, or short family emergency needs. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place. Staff spoken with reported they could discuss their working hours with the manager or Lead GP if they needed greater flexibility in their role or needed to change. Staff reported that they could speak without fear of retribution or breach of confidentiality with the practice manager. Staff told us that their wellbeing was considered, and their views respected, and concerns acted upon. These included, for example, reasonable adjustments and support provisions for staff undergoing medical treatment, as well as for those requiring short-term assistance due to family-related responsibilities.

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. They acted on the best informationabout 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 their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

Areas identified during our remote clinical searches and on site were promptly actioned by the leadership team.

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 collaborate for improvement.

The provider worked with other practices within their Primary Care Network (PCN) to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

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.

The practice had a quality improvement plan in place to help drive improvements in services This focussed on the appointment system. All staff were encouraged to put forward and test out new ways of working.

The practice was a GP trainee practice and a research practice with Keele University. The service completed regular clinical audits and the outcomes shared at clinical meetings and education meetings.

The service had a strong and clear awareness of their local population demographics, including hard to reach vulnerable groups of patients, in an area with a deprivation score of 2 out of 10. They had plans to develop an ongoing strategy ontheir involvement with a local mosque and contact more local community groups to further improve population health, education and take measures to further address health inequalities.