Francis Grove 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. The leaders we spoke with told us that the shared vision was rooted in patient safety and providing high quality care. They said that it was the “principle that guides all staff, including reception staff” and that as a practice they understand the challenges and the needs of people and their communities.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. This included looking at the number of GP sessions currently available and ensuring their triaging system could manage the increasing demand.

The practice had an active patient participation group (PPG) who were well established and engaged with the practice. They represented patients on a wide range of health conditions and patient perspectives. PPG members told us “they share everything with us” and “always involve us in decisions about the service.”

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Improvements were required for all staff to feel that all leaders fostered the culture of inclusion and openness. Some staff felt some leaders did not always embody the culture and values of their workforce and organisation.

All leaders we spoke with had the skills, knowledge, experience to lead effectively. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support. They told us that as a leadership team they met weekly to discuss strategy, share updates and share key information... We discussed this with some of the managers and whilst they gave us some examples of positive staff experiences, they acknowledged that if these concerns were raised the practice would ensure steps were taken to address this.

Staff told us most leaders in the practice was approachable and responded to any concerns raised. Staff also told us most leaders modelled the values of the practice.

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.

Managers told us that they felt the service fostered a positive culture where people felt they could speak up and their voice would be heard. Managers said that they made sure staff were aware of the external freedom to speak up guardian. We observed this and saw that where staff had concerns, they felt confident to raise them.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. The practice had an external freedom to speak up guardian who was fully trained to deal with concerns raised with them. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

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

Policies and procedures to promote diversity and equality were in place. We saw processes were in place for senior leaders to address concerns related to discrimination if required. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to working patterns, equipment and duties for staff who needed these to stay in employment.

Managers said that they had procedures in place to deal with bullying and harassment which included having a code of conduct policy that outlined what behaviour was acceptable. Investigations were carried out if concerns were ever raised.

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 share this securely with others when appropriate.

All staff we spoke with were clear on their individual roles and responsibilities. The practice had a list displayed in various staff areas outlining staff with lead roles for all areas, such as safeguarding, quality assurance and infection control. This ensured that this information was always readily available to all staff if they needed to speak with the person with lead responsibility. This information was also given to all new staff when they joined the team.

Processes were in place for staff to be supported through regular support and supervision sessions. Managers met with staff regularly to complete appraisals and performance reviews. We saw evidence of completed appraisals in staff records.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures.

There was a series of different meetings to ensure good governance. There were regular clinical meetings including 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 work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network and GP Federation to offer extended access, and flu and covid vaccination programmes. Staff had adjusted improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

Staff described their relationship with the ICB as “strong and positive,” with one of their GP’s attending meetings with them every quarter. They said these meetings were particularly useful for receiving updates.

Other partnership working included a member of staff being on the board of the local GP Federation, and regular attendance at the practice managers forum.

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 had a range of initiatives to encourage awareness, improve patient understanding and generally improve quality of life. For example, they held an annual “Dementia Day” where they invited external agencies, care support teams, and social prescribing services to come together and raise awareness and provide additional support to patients and their families. They also used this day to update patients care plans, do medication reviews, and review the carers plan. Patient fedback that these events were useful because they could update everything as well as access other support and advice services all at the same time. This improved uptake of reviews and gave support to carers.

They had an annual flu day and took this opportunity to also do blood pressure checks, and booking patients in for blood tests. These days helped them get access to patients who could traditionally be hard to get access to. The practice told us these days had increased identification of other underlying conditions.

The practice funded a hormone replacement therapy (HRT) clinic where patients could be seen by a clinician with specific HRT training. Staff told us that feedback received from their patients indicated that patients valued the provision of the clinic.

They had put in place robust processes for child immunisations. They did a lot of work at looking at who was not attending to understand why. Most recent data showed that they had achieved 95.6% overall for all childhood immunisations.

The practice met with the PPG group every other month. They said that the group consistently provided constructive feedback, which helped the practice to improve. For example, they were actively involved in supporting the dementia and flu day initiatives which were always successful.