Drs Dawes, Narasimhan and Spiller

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 practice was led by 3 partners and a business/practice manager and supported by other leadership roles. There was a collaborative approach to leadership within the practice and an open culture.

The service had a clear shared vision, strategy, and culture. Its vision was to work together with patients and staff to provide the best primary care services possible, working within local and national governance, guidance and regulations. This vision was supported by a mission statement, values, aims and objectives that staff were familiar with. As part of its business plan, the practice was considering expanding the building to create additional clinical space.

Feedback we received from staff regarding the culture at the practice was positive, describing an open and positive working culture where everyone felt valued and supported. They told us there was a friendly team atmosphere.

The practice benefited from experienced leaders who had the skills, knowledge, experience and credibility to lead effectively. They had established clear oversight mechanisms that supported consistency, strong governance frameworks and organisational stability. Leaders at all levels demonstrated a good understanding of the context in which they delivered care, treatment and support, and they modelled the culture and values of the workforce and the wider organisation.

Staff told us leaders in the service were visible, approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. We saw the leadership team worked well with other services in the local primary care network and were engaged in the development of primary care services within the local area.

We received 10 staff feedback forms which contained positive feedback demonstrating staff felt leaders were always visible, approachable and compassionate. We also spoke to staff in remote interviews who corroborated this. Staff said they were fully supported at work and could raise and discuss issues.

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. Feedback from staff surveys showed that staff knew how to access relevant policies and procedures, including the whistleblowing policy, and were aware of the nominated Freedom to Speak Up Guardian who could support them to raise concerns. There were multiple opportunities for staff to provide feedback on how the service was operating. These included regular meetings, annual staff surveys, a staff suggestion box, and an open approach from leaders who encouraged staff to speak directly with the management team about any concerns or ideas for improvement.

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 in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available. Staff feedback demonstrated there was a no-blame culture at the service.

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 provider 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 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.

Leaders and 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.

The practice carried out regular audits to monitor service provision and improve the quality of services provided. For example, medicine related audits, access, complaints, significant events and patient feedback.

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

Leaders told us they worked with stakeholders and the local community. The practice was part of a Primary Care Network (PCN), and the GP partner was the clinical director. They worked collectively to provide enhanced services to patients, such as extended access. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

The practice offered extended access, flu and covid vaccination programmes. Staff had made adjustments and collaborated with local services to further support community healthcare services.

There was an active Patient Participation Group (PPG) in place, with meetings held on average every 2 to 3 months. We spoke with 5 members of the group, who were highly engaged in providing advice, information and health promotion activities within the local community to educate and support patients. The group told us they worked in close partnership with the practice management team and produced a newsletter to keep patients informed about services available both within the practice and across the wider community.

The practices PPG also contributed to the wider Primary Care Network (PCN) PPG and actively supported community health initiatives. Representatives described the practice as transparent, responsive and were regularly updated with information such as complaints data and Friends and Family Test results.

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 and contributed to safe, effective practice and research.

The leadership team held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided. They also worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.

The practice had a quality improvement plan in place to support ongoing development and drive improvements in service delivery. They worked collaboratively with stakeholders to enhance the experience of people using the service and to address the wider needs of the local community.

The practice operated as a training practice, with 4 GP’s serving as trainers. In addition, they were research active, and the practice manager had been appointed as a Primary Care Champion, working with local practices to support research activity and participation in studies. Research projects included, investigating respiratory infections, management of heart failure and how to increase physical activity.

As part of future development there were plans for the practice to carry out Abdominal Aortic Aneurysm (AAA) screening for patients (AAA screening is an ultrasound test to detect swelling in the abdominal aorta).