Pembroke House 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 assessed all quality statements in the well-led key question.

At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to good. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles.Leaders worked with the local community including care homes and the service’s PPG to deliver the best possible care and were receptive to new ideas. The service had a strong focus on continuous learning, innovation and improvement across the organisation. However, there were shortfalls in safe recruitment practice and gaps in monitoring of mandatory training completion. There was also poor monitoring of clinical care, as proven by our remote clinical searches. The service acted quickly during the assessment to address these issues.

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 which drove high quality sustainable care. This was based on understanding challenges and the needs of people and their communities.

Senior staff had contributed to the development of the service’s vision and strategy, which was kept under review.The business partner maintained oversight of the strategic development of the service. Staff described the culture as supportive with good work atmosphere. Staff told us there was an open-door policy where they could access and speak freely with leaders. There was an emphasis on the safety and wellbeing of staff. Staff were informed of changes in the service through regular meetings, emails and weekly staff bulletins.

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.

The leaders were visible and approachable and responded to any concerns raised. We received positive comments from staff regarding the support provided by team leaders. For example, the leaders cared about the staff’s wellbeing during periods of absence due to personal or family circumstances and coordinated flexible working arrangements to support their return to work. Leaders were aware of the challenges of delivering good quality care and were striving for improvements.We received different examples of how the service implemented changes in response to staff feedback. For example, the service allocated more time for staff to manage administrative work and modified the layout of document management system to promote effective working.

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. The service had a whistleblowing policy which clearly laid out the process of raising concerns within the service and externally, including the name and contact details of the freedom to speak up guardian (FTSUG - a person who supports workers to speak upwhen they feel that they are unable to do so by other routes). The policy was accessible to all staff on their computer system. Most staff were aware of the FTSUG role and how to access their support.

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.

There were policies and procedures to promote equality and diversity. Most staff (94%) had up to date equality and diversity training. Staff gave examples of how the service made reasonable adjustments to support their family circumstances and health needs. The management gave an example of equal opportunity within their workforce.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We identified shortfalls in safe recruitment practice and gaps in monitoring of mandatory training completion. There was also poor monitoring of clinical care, as proven by our remote clinical searches. The service was responsive to our findings and immediately developed action plans to address the issues. To enhance governance, the service developed a new centralised electronic tracker system to monitor risks and issues of the service. For example, reminders would be sent to the responsible staff when audits, training completion, or policy reviews were due. However, leaders met with staff regularly to complete appraisals and performance reviews. The service held regular leadership and staff meetings to ensure all staff members were aware of changes to service delivery and latest guidance. Meeting minutes were taken which was shared with staff who were absent. There were weekly staff bulletins to share wider news about the service. The service ran weekly drop-in sessions with one of the senior leaders to listen to staff feedback, ideas or concerns. The service held strategic meetings twice a year to discuss strategic development and workforce planning. Staff could access all required policies and procedures on their computer system. The service had a business continuity plan which provided guidance and information for staff to follow in the event of systematic failures. The provider had oversight of contracts with external providers and liaised with them regarding any issues raised.

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

Leaders worked with other services in the local primary care network and were engaged in the development of primary care services within the local area. For example, the service led the enhanced access service in the locality to provide seven-day access of primary care. The service worked with the local ICB and was responsive in their communication. We received 11 feedback responses from care homes that the service worked with and all of them were very positive. The care homes described the service as approachable and very responsive. The care homes provided examples of changes made in response to their feedback and learning from incidents was shared with them. One of the care homes commented “We are very appreciative of the practice and the support they provide to both staff and residents. Their professionalism, responsiveness, and dedication make a real difference to the quality of care our residents receive, and we are grateful for their ongoing partnership.” The care homes appreciated the new role of community matron employed by the service who was the main point of contact for the care homes. The matron knew the people using the services well and promoted continuity of care. The service had a GP with expertise in learning disability and the care homes for people with a learning disability commented highly that the GP understood their people and was very supportive. The PPG was re-established in the last year as it was dispersed during COVID. There were about 55 people in the service’s PPG at the time of our inspection. The service worked collaboratively with the PPG to collect people’s feedback and improve people’s experience. For example, a survey was carried out recently by the PPG with the help from the information technology (IT) lead of the service to develop an online form to facilitate the survey. Paper survey forms were also available.

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 contribute to safe, effective practice.

The service was a teaching practice for GP registrars (a doctor training to become a GP) and provided placement for foundation year 2 doctors (a junior doctor in their second year of hospital training after medical school, gaining experience in diagnosing and treating patients under supervision). This demonstrated the service’s focus on promoting learning. The service was proactive in making improvements to improve people’s outcomes and reduce unnecessary hospital admissions. For example, the service had undertaken a weekend care home support pilot project, working with local care homes where high hospital admission rates had been identified. The pilot meant a dedicated GP and care coordinator were on duty at the service at weekends to manage health concerns of those people specifically. The GP had full access to their clinical records which helped in continuity of care. This pilot project had successfully reduced hospital admissions, as some people were managed by the GPs during weekends and saved the need for hospital admission. Although the project ran effectively for four months, it ended due to funding constraints. The service was innovative in tackling the difficulty of access. To improve appointment availability, the service successfully recruited a former GP and a pharmacist who had left the service due to relocation to carry on their initial clinical job roles remotely. Both staff members already had a good understanding of the service’s systems. Therefore, they could pick up the job quickly, perform efficiently, and with a better sense of belonging to the team, despite the remote nature of the work. The service adopted the Heidi Health Tool, an artificial intelligence (AI) medical scribe software designed to transcribe people’s visits, generate clinical notes, complete documents, and dictate letters.The service demonstrated the AI tool to PPG members for their feedback before the launch. After launching, the service received positive feedback from both the GPs and people using the service, as the GPs could focus more on the consultation, rather than on typing and administrative tasks. This process of using AI was underpinned by the relevant safeguards to ensure safety and mitigate risk, which included compliance with NHS Digital clinical risk management standards.