Archived: Collington 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 has changed.

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 to provide a safe and sustainable care. The service had a clear business strategy which included improving patient access and experience of the service. For example, the service had introduced monthly patient feedback surveys, which showed 91% to 93% of respondents reported good/very good experience of the service over an eight-month period.

Staff told us they cared about their work and were committed to getting it right. They felt valued by the service who offered them support and opportunities in their role. They respected the partners and told us they were accessible and receptive to feedback. Staff told us they felt able and supported to raise questions or concerns with the management team.

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.

Staff told us leaders in the practice were approachable and responded to concerns raised. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services in the local area.

Systems and processes were being established and refined by managers to ensure they were effective. The leaders demonstrated that they had the capacity and capability to ensure that the organisational vision could be delivered. They acknowledged the challenges involved in providing good sustainable care and did so with integrity, openness and honesty.

Staff told us their management team and colleagues acted with openness, honesty and transparency in the dealings with one another and people. Staff told us they were trusted to work with autonomy but had the support of the management team.

The service had a nominated internal speak up champions for staff to approach if they felt unable to directly raise concerns with the management team. Staff also had access to external speak up champions if they felt more comfortable to do so. Concerns raised by staff informally and formally were all recorded, investigated and responded to, learning identified and shared to drive improvements.

Staff told us they valued their colleagues and the opportunities to support one another, share learning and diversify their knowledge and skills base. Staff felt confident raising concerns or questions.

There were established, effective and inclusive systems in place to demonstrate leaders had reviewed, considered and improved the culture of the practice. The management team sought staff views and opinions directly. Reasonable adjustments had been made in response to health and safety considerations.

The service now 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 information about risk, performance and outcomes, and share this securely with others when appropriate.

Since taking over the provision of services in 2024, the service had embedded improved systems.

They now conducted checks on individuals and collective performance to ensure adherence to safe practice. They identified where improvements could be made and assigned priority actions to improve patient outcomes. Significant events were learnt from, so similar incidents did not re-occur. Concerns raised in clinical meetings were actioned and resolved.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly, supervision arrangements were in place, appraisals and performance reviews were conducted. The service 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.

The service collaborated with relevant external stakeholders and agencies. Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. They worked with other practices in their primary care network to offer extended access appointments. Staff and leaders engaged with people, communities and partners to share learning with each other that results in continuous improvements to the service.

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.

Staff and leaders had a good understanding of the importance of and how to make improvement happen. They valued protected time for learning and invited staff from their other services to events to exchange ideas, experiences and best practice with colleagues.

They were accessible to staff and people, investing time and resources into listening to people’s experiences and made changes to improve the service. They referred to their patient participation group as critical friends and valued their experiences and contribution to improving the service.