Drs Sells and Dr Kyaw Also known as Lyngford Park 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 good. At this assessment, the rating remains the same.

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. 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 had contributed to the development of the service’s vision and strategy, which was kept under review. Staff described the service as supportive with an open culture and a focus on people’s care. Daily huddle meetings, regular team meetings and emails kept staff informed of changes in the service and provided an opportunity to discuss concerns.

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 service were visible and approachable and responded to any concerns raised. Staff from different roles gave examples on how they were well supported by their leaders at work and flexible work arrangements were made for personal or family circumstances. Leaders were aware of the challenges of delivering good quality care and were striving for improvements.For example, to increase appointment capacity, the service carried out an extension of the building in recent years to provide more clinical space.

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

Staff felt confident to raise any concerns with their managers and leaders. Most staff were aware of the role of a freedom to speak up guardian (FTSUG was a person who supported workers to speak upwhen they felt they were unable to do so by other routes). The service had established Freedom to Speak up arrangements with the Local Medical Committee (local representative committees of NHS GPs). The name of the FTSUG was on a poster at the reception. However, no contact details were listed on the poster or in their whistleblowing policy. We raised this with the service which took immediate action to update the policy and poster to include the contact details.

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.

There were policies and procedures to promote diversity and equality. Staff gave examples of how the service made reasonable adjustments to support their health needs. Staff feedback demonstrated there was an inclusive culture at the service.

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 information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service had established governance processes that were appropriate for their service. Staff could access all required policies and procedures on their electronic system. 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, with learning and development identified.

Managers held regular 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. The service also held short daily whole team morning meetings to catch up about operational issues, including capacity, appointment waiting time and this was documented. Staff took patient confidentiality and information security seriously.

The remote clinical searches evidenced an established process for monitoring clinical care which was effective.

There was a system to monitor the completion of mandatory training and evidence showed that staff training was up-to-date.

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

The service worked with other services within their primary care network (PCN) to offer extended access appointments outside normal working hours. (A PCN is a group of general practices that work together to provide a wider range of services to the local population.) The service worked jointly with the proactive care team from the PCN to optimise care for people living in care homes who received care and treatment from the service. Feedback from the care homes was positive and they considered people’s needs were being met by the service. The service worked closely with the patient participation group (PPG). A senior GP partner and the practice manager regularly attended the quarterly PPG meetings. The PPG members described how the service valued their involvement and they had two-way communication with the service. They gave various examples on how improvement was made based on their feedback. The current PPG size was small with 5 members despite previous PPG recruitment campaign. The service and the PPG further planned to recruit new members through activities at the nearby community centre.

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.

Staff were encouraged to develop their skill set to enable them to take on new roles, responsibilities and further their career. For example, the service supported staff in developing from receptionist to manager, and a healthcare assistant was supported in training to become a nurse. The service was a training practice for doctors training to become GPs. To enable the service to be a training practice they must meet specific criteria including having adequate facilities and a supportive learning environment.

All staff were encouraged to put forward and test out new ways of working. For example, the introduction of a walk-in clinic for taking blood, to improve access particularly for people with long-term conditions who require monitoring. The service led a women’s health initiative, aiming at improving people’s outcomes. The initiative was in progress and delivered jointly with other services in the PCN and the local hospital. The service developed a new referral form for women with abnormal menstrual bleeding to collect more information on specific risk factors for endometrial cancer (cancer of the womb lining). This helped to identify women at high risk earlier for investigation and treatment and reduce unnecessary anxiety and investigation for women of very low risk.