Sunniside Surgery Also known as Sunniside Medical Practice

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.

Leaders understood the challenges and needs of people and their communities and worked well with partner agencies to support people effectively. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Values were actively integrated into daily practice, establishing an open and respectful culture. All staff and people felt psychologically safe and empowered to speak up and raise concerns and contribute to help learn and improve. Staff were highly motivated and consistently felt well-supported by leaders and team members. Staff told us they felt valued, included, and supported because leaders listened and recognised their work. Managers were approachable and promoted open dialogue, invited ideas and addressed areas of concern.

Leaders invested in learning and development for all staff to assist them in best practice and the fulfilment of their roles.

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 and modelled the values of the practice. It was evident that patients were at the heart of everything the practice did, and leaders demonstrated the importance of staff wellbeing to support them in maintaining good outcomes for patients.

Leaders had insightful and impactful oversight of service quality priorities and risks. There were regular management and staff meetings to ensure all staff members were involved and aware of changes to service delivery as part of the team.

Staff told us leaders in the practice were visible, approachable, and quick to respond to any concerns. 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.

Feedback received, both directly by the practice and to the CQC from patients and staff was consistently, highly positive.

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

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The practice had an open culture where staff felt confident to speak up about any concerns. Staff reported that their views were heard and that they felt safe raising issues without fear of negative repercussions. Leaders encouraged honesty and transparency, creating an environment where staff were comfortable sharing concerns.

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. 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. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. Adjustments had been made to ensure all staff were valued, for example adjustments to accommodate flexible working where appropriate, were in place.

The service had clear responsibilities, roles, systems of accountability and for the majority 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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff we spoke with told us the leaders had an “open-door” policy and were always responsive and available to provide support. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service together with named leads in place for key areas. Recruitment processes were effective, with appropriate checks carried out for new staff.

Staff could access all required policies and procedures and understood the importance of patient confidentiality and information security. There were arrangements for identifying, managing, and mitigating risks and a major incident plan was in place. Staff took patient confidentiality and information security seriously.

Managers held 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.

During the assessment we identified issues with the leaders’ clear oversight of new online staff management training system. This resulted in difficulty in establishing if mandatory training had been completed in line with the practices training policy guidelines. We also noted that not all authorisations for the Patient Group Directions (PGD’s) were accurately in place. A PGD is a written, legal framework in the NHS allowing registered health professionals (e.g. nurses, pharmacists) to supply/administer specific medicines to pre-defined groups of patients without a doctor's prescription. Leaders addressed these issues once the assessment visit was complete.

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

The practice was part of the local GP Alliance Additional Roles Reimbursement Scheme (ARRS) providing additional speciality to the service such as pharmacy, social prescribing, physiotherapy and mental health.

The provider worked with the other practices within their primary care network to offer extended access. Staff worked closely with community healthcare services, with staff taking part in regular multidisciplinary meetings to support coordinated and integrated care. The practice also delivered LARC clinics for both their own patients and those across their PCN, helping to improve access and ease pressure on local secondary care services.

The practice engaged with the Integrated Care Board (ICB) primary care and their medicines management teams. The practice hosted trainee doctors to obtain experience of general practice.

The practice held Armed Forces Veteran Friendly accreditation. This is a recognised program run by the Royal College of General Practitioners (RCGP) and NHS England for providing better care for veterans.

The practice did not have a Practice Participation Group. This had been the case since the COVID-19 Pandemic in 2020. They had worked hard to attract members to reestablish the group including distributing leaflets, taking part in local events, sending messages to patients and sharing information across various media platforms. They have been unable to attract new members to date.

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 and research.

The service was an active teaching practice for year 3, 4 and 5 medical students. In the compliment letters and cards many were from the medical students.

All staff regularly listened to feedback from patients and the community. The majority of patient feedback was generated on a monthly basis from the Friends and Family Test, and we saw the feedback was largely positive. Staff regularly reviewed feedback from patients and the wider community to shape and assess new ways of working. For example, after receiving some negative comments about the television in the waiting room, staff proposed switching to a radio. The practice obtained a music licence and introduced this change, which was well received by patients. It had helped create a calmer atmosphere and offered greater privacy for conversations at the reception desk.

Leaders also took staff feedback into account, along with learning from complaints and incidents, to implement changes and continually improve service quality. One suggestion from staff was to introduce a pet board in the waiting room displaying photos and names of staff pets, which had been enjoyed by many and helped engage children and reduce anxiety among adults.

Leaders encouraged staff to put forward and test out new ways of working. We saw evidence of a broad range of audits and quality improvement initiatives focused on enhancing performance, outcomes, and patient experience. These included clinical audits, pharmacy reviews, benchmarking prescribing patterns against national data and implementing a cloud‑based telephony system.