Cumberland House Surgery

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• 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 assessed all the quality statements in this key question. At our last assessment, we rated this key question as good. The rating remains good following this assessment. We found the provider had clear and effective governance processes, which supported the safe delivery of care. The provider had a vision and mission statement to provide a good quality service that was responsive to people’s needs. Work was needed to ensure all staff understood the future development plans for the service. Staff understood their roles and responsibilities and those of other members of the team and staff understood the lines of accountability. Overall, staff told us they were positive about working at the practice. They felt valued and supported by colleagues and leaders. They felt able to contribute to decision making about how the service operated and that their opinions would be listened to. However, some staff told us improvements could be made to communication between teams and support provided. The provider supported learning and innovation and worked closely with stakeholders to improve services for patients. Leaders demonstrated that they understood the challenges to quality and sustainability. There were appropriate arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care and treatment provided.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a mission statement across the service to provide a good quality service that was responsive to people’s needs. The provider had an understanding of the challenges and the needs of the patient population. We asked staff to complete a questionnaire to inform this assessment. We had feedback from 14 staff and 42% said they did not consider there was a clear vision for the future for the practice. The provider told us that the staff survey was used to gain staff views to inform the development of the practice and that the shortfalls identified by staff had been responded to. The provider told us that future team meetings would be used to clarify the way forward for the service. There were clear responsibilities for clinical and non-clinical staff. There were arrangements to communicate between and within teams of staff at the service. The majority of staff told us that they felt that there was a positive, supportive culture at the practice. Some (21%) indicated that the culture could be stressful when the workload was high. This was brought to the attention of the provider.

Leaders understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge and experience to lead effectively. The leadership team worked with other practices in the primary care network (PCN) and were engaged in the development of primary care services within the local area. The provider monitored and acted upon data about outcomes for patients. They made improvements when required. Feedback from people who used the service was positive with regards to the capability and compassion of the staff and leadership team. We asked staff to complete a questionnaire to inform this assessment. Overall, staff told us that leaders were visible and approachable and that there were processes to communicate within and across teams, a minority told us improvements could be made to communication across teams.

The majority of staff who fed back to us told us they could raise concerns about the service and these would be welcomed. Feedback from staff surveys showed that overall staff knew how to access policies and procedures and the nominated people to support them to speak out such as the whistleblowing policy and the Freedom to Speak Up Guardian. There were opportunities for staff to provide feedback on how the service was operating. For example, meetings were held, staff surveys circulated, and the provider told us how they encouraged staff to approach the management team with any concerns or ideas for improvements. Feedback from the staff surveys showed overall staff felt supported by the management team.

The provider valued diversity in their workforce. They told us how they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider made reasonable adjustments to support staff to carry out their roles. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. The practice had an equality, diversity, and inclusion policy.

There were clear and effective arrangements for governance, management and accountability. A clear management structure was in place with designated staff members who acted as leads for clinical and non-clinical areas. Staff roles, responsibilities and lines of accountability were clear. There were effective arrangements for identifying, managing, and mitigating risks. We saw how information about risk, performance and outcomes were monitored and how change was discussed and implemented following feedback from people who used the service, staff and relevant stakeholders. Information was used effectively to monitor and improve the quality of care and treatment provided. A regular suite of searches of the clinal record system were run to identify people’s needs and ensure these were being met. Staff could access all required policies and procedures. Meetings were held with practice staff and external professionals to identify clinical risks and act appropriately. There were clear arrangements in place for the availability, integrity and confidentiality of data, records, and data management systems and staff took patient confidentiality and information security seriously.

We found examples of outstanding practice in how the provider worked in partnership with other organisations and communities. The provider worked in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop effective services. They worked collaboratively with the primary care network (PCN) and clinicians from the practice held active roles in the PCN. Services provided by the PCN for all people included a spirometry service, Covid and flu vaccination clinics and an acute care service. The acute care service was provided over the winter months and offered additional on the day appointments for people presenting with acute illness. The PCN provided a ‘Full Circle Programme’ that supported people at every stage in their lives by working with local health and care services, advertising these and supporting people to access them. The practice had established a women’s health clinic to support and work with the PCN to enhance patient care and GP practice collaboration. A GP from the practice had established a perinatal clinic which resulted in people receiving a timely service to review their needs by the same health care professional. The safeguarding lead had set up peer support group meetings for the safeguarding leads in the PCN to discuss topical issues and learning and they acted on any issues identified to make improvements. They had taken the lead on ensuring key people were informed about difficulties being experienced to bring about change, for example the difficulty in liaising with health visitors and school nurses due to staffing shortfalls. The practice had a Patient Participation Group (PPG). We met with representatives of the PPG, and they told us the provider was working with them to identify people’s views about the operation of the service. The provider sought feedback from patients and reviewed external sources of feedback such as the National GP Patient Survey and the NHS Friends and Family Test and took action to address any shortfalls identified. For example, following peoples feedback the length of appointment was increased.

There was a focus on continuous learning and improvement across the service. Systems for assessing the quality of the service and outcomes for patients were in place. There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence. The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality. For example, a service had been established to reduce hospital admissions and improve the quality of life of frail patients. A service had been put in place to improve women’s health. A GP from the service worked in health research on perinatal mental health which enabled them to influence practice in this area. They had also established a perinatal clinic to support people. The practice was a training practice and supported medical students from two universities. Teaching sessions were provided for undergraduate medical students. As part of this patients were asked to give a presentation on their experience of healthcare services and interactions with clinicians to enable students to reflect on and develop their communication skills. The practice was also involved in clinical research.