City Way 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 remains the same.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff told us the GP partners were managing both clinical and human resources responsibilities, which they felt was difficult to sustain. Staff described a generally supportive culture, with team members working together to manage demand and maintain service delivery. Although pressures on access and capacity were acknowledged, staff reported a shared commitment to improving patient experience and contributing to ongoing service developments. While most staff said they understood the practice’s overall direction and aims, some were not aware of the practice’s mission statement, vision or values.

Leaders were described by some staff as visible, approachable and supportive, and many felt confident raising concerns with them. Some staff noted that communication and relationships with leaders had improved over time, contributing to a more open culture.

However, some staff reported frictions in the leadership team and that they felt leaders occasionally pursued their own vision without considering alternative views.

Some felt that leaders occasionally pursued their own vision without initially considering alternative views, although they also said leaders were willing to listen and adapt following discussion.

Staff we spoke with told us they were not aware of who the Freedom to Speak Up Guardian was, but said they felt able to raise concerns directly with leaders or management and would look for the relevant policy if needed. During the onsite visit, we saw information displayed in staff areas outlining how to speak up and who to contact. Leaders told us they had recently reminded staff of these arrangements and incorporated Freedom to Speak Up guidance into training to strengthen awareness and confidence in the process.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by promoting staff equality and equity. The practice had systems to promote equality, diversity and inclusion in the workplace. Some staff told us they had received support and developmental opportunities as well as reasonable adjustments to accommodate individual needs.

Governance systems required strengthening, as some processes were not operating effectively.

At the time of the assessment, the practice did not have structured clinical supervision sessions which limited the effectiveness of governance and ongoing assurance. Leaders have since developed and implemented a plan to introduce formal supervision arrangements.

Practice processes did not ensure effective oversight of task management. We identified a backlog of tasks showing as requiring action on the practice’s system. We reviewed a sample of these and identified action been taken but the task had not been marked as completed. This meant the practice was unable to demonstrate which actions were still required and prioritise effectively. Following inspection, the practice identified an action plan for reviewing and completing outstanding tasks. In addition, they implemented a task management policy. However, we were unable to determine if the new process was embedded in practice.

We found systems to support the monitoring of emergency equipment were not embedded. We identified some equipment which had expired and some which had not received any monitoring. While the practice took immediate action to remedy these oversights, we were unable to determine if improvements were embedded in practice.

Systems to ensure practice policies reflected national guidance were not always embedded. We identified the practice’s complaints policy did not reflect national guidelines. Following inspection, the practice told us they had updated their policy and shared the revised version with all staff.

The practice acted quickly to address the concerns we had identified. However, we were unable to assess the impact of these improvements and if they were embedded in practice.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They shared information and learning with partners and collaborate for improvement.

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

The practice reviewed complaints, significant events, and audits, sharing learning with staff to support reflection and improvement. Actions were implemented in response to identified issues demonstrating a commitment to continuous improvement.

The practice had a quality improvement plan in place to help drive improvements in services.