Park Green 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

The provider had not established governance processes that were appropriate for their service. There was not an effective oversight system to monitor training compliance for staff. Staff were not aware of the incident criterion in the significant event policy. The complaints policy was not followed. However, Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive. 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.

This service scored 62 (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 practice charter. This was based on training, mutual learning, communication, and understanding the needs of the people and their communities.

However, not all staff had contributed to the development of the practice charter.

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 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 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. Staff were aware of how to raise concerns.

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

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

The provider had not established governance processes that were appropriate for their service. There was not an effective oversight system to monitor training compliance for staff. Following the assessment, the provider told us staff appraisals and training was up to date but did not provide evidence of this for all staff. Staff were not aware of the incident criterion in the significant event policy. The service had clear responsibilities, roles and systems of accountability. 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 shared this securely with others when appropriate. 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 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.

Staff and leaders engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the service, such as working with the primary care network. They used these networks to identify new or innovative ideas that could lead to better outcomes for people.

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 contributed to safe, effective practice and research.

We reviewed clinical audits provided by the practice, they contained good data and learning outcomes.