Park 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 requires improvement. At this assessment, the rating changed to good. Governance had improved since the previous inspection, with strengthened clinical oversight, audit processes, safeguarding arrangements, referral monitoring and organisational learning. However, leaders had not always identified and addressed all risks through governance systems, limiting assurance in some areas of the service.

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 vision, how this was to be delivered and a clear set of values. The values were based on safety, equality and diversity, improvement and a positive culture. Staff were aware of the mission statement in place.

The practice vision was to be clinically excellent and learning led, as well as intending to move to community-based services as set out in the NHS 10-year plan. Staff we spoke with referred to the practice vision as modern general practice and referenced being focused on patients and safety. The practice told us they also aimed to become a more training-oriented organisation and supported salaried GPs to undertake additional training relevant to service development. Staff were given opportunities to develop specialist skills, take on leadership roles and contribute to shaping new ways of working within the practice.

The practice was aware of its patient population group and likely future needs.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Leaders had responded positively to findings from the previous inspection by strengthening governance, clinical oversight and quality improvement processes, including improvements to long-term condition management, safeguarding arrangements, clinical coding, referral monitoring and organisational learning.

We saw the practice worked with other practices in the PCN as well as ICB. Staff we spoke with felt there was an open and supportive culture within the practice. Staff reported an ‘open door’ policy. A staff newsletter was produced and circulated to staff. Staff from whom we received written feedback were generally positive about working at the practice and the approachability of other colleagues.

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

Staff described a culture in which concerns could be raised openly and where appropriate action would be taken. The practice had identified internal Freedom to Speak Up contacts, including senior management staff, and staff were aware of external escalation routes through the local ICB Freedom to Speak Up Guardian.

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.

Policies and procedures to promote diversity and equality were in place. Adjustments

had been made to ensure all staff were valued, for example adjustments to support disabled staff. Staff were treated equally and we also saw evidence that staff wellbeing was supported during periods of personal difficulty. Leaders demonstrated a compassionate and flexible approach, providing appropriate support to staff as required. This reflected a positive culture in which staff wellbeing was recognised and supported.

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, there were gaps in governance as leaders had not always identified or addressed risks through governance processes, including concerns relating to medicines management, safeguarding oversight, incident recording, emergency preparedness and clinical task management. This limited the provider's ability to demonstrate effective oversight and assurance across all areas of the service.

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 provide 1 to 1 support. One partner was the lead for operational matters and governance, and the other for clinical matters and some governance issues.

We did however find there continued to be some issues regarding medicines management which had not been addressed before our inspection. Staff could access required policies and procedures. Managers held regular meetings both across the whole practice as well as for specific groups of staff. Information was cascaded as needed and there was a mechanism in place to ensure staff had noted information they were required to read.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their 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.

Since the last inspection the practice has taken steps to improve the service provided. Steps have been taken to increase the use of digital systems. Staff told us a suggestion box is available and there were examples of those acted upon. For example, tools to support coding of patient information. Feedback from patients has also been acted upon in order to improve the service e.g. appointment times for screening.