Archived: Lichfield 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

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. 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. There was a culture of improvement with staff given time and resources to improve and acquire new skills.

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. These were based on delivering excellent, high quality, compassionate person-centred care, caring for the environment, investing in staff, and promoting preventative health by empowerment, engagement and collaboration with all partners.

Staff we spoke with told us they worked within a focused, friendly and inclusive team, and they felt supported by service leaders. They told us that they felt comfortable talking with the service leaders regarding complaints or incidents and could do so without fear of retribution. The lead GP at the service told us incidents and/or significant events were dealt with promptly when they occurred. Reflection and analysis on incidents/events that had occurred, was viewed as a learning opportunity to ensure that an incident/events of the same or similar nature would be limited in the future. The service was aware of the increase to the local population and transient nature of some its patient population and was working with partner agencies to address future challenges.

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 there was inclusive and effective leadership. The leadership team worked with the other practices within their local PCN and were engaged in the development of primary care services within the local network area.

Practice leaders optimised their skill mix and had proactively recruited to a range of roles themselves and via the PCN. These roles included for example, Advanced Nurse Practitioners, First Contact Physiotherapists and Clinical Pharmacists. The service leaders also supported the upskilling of existing staff to ensure that their skills meet current and future practice needs. Leaders spoke with the assessment team about the importance of having oversight of the work of clinical staff, to ensure these members of the team were working within their scope of practice effectively.

We noted that the service did not undertake any recent staff surveys to obtain feedback from staff or to gauge how staff working at the service felt about their role.

The service leaders told us they had worked to foster a positive culture where staff felt they could speak up and their voice would be heard. We viewed the service training log for all staff and identified that no members of staff had any recorded training relating to Freedom to Speak Up. We discussed this with the service, and they told us they would be arranging this training for staff.

Staff told us leaders were visible and approachable and responded to any concerns raised.

There were processes for staff to speak up. The practice had Freedom to Speak up arrangements in place which included an internal Freedom to Speak Up Ambassador however we did not note any arrangements which referred to who the external Freedom to Speak Up Guardian(s) were.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service 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. Service leaders had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed concerns and emerging risks. The service held separate clinical staff meetings where clinical matters were discussed. As part of this assessment, we viewed six sets of internal administration and reception staff meeting minutes provided to us by the service and found none of the minutes provided had a list of staff members who attended the meetings. Managers confirmed they recorded any actions arising from these meetings and ensured they shared these with staff who were not present.

The service used digital services securely and effectively and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There was a focus on continuous learning and improvement at all levels across the service. There were clinical meetings to discuss cases and best practice, as well as all staff practice meetings where internal changes to processes were discussed. Leaders encouraged reflection and collective problem-solving, and there were processes to ensure that learning happened when things went wrong, and from examples of good practice. Staff were supported to develop their skills around improvement and innovation. Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. Staff and leaders had strong external relationships that supported improvement and innovation.