Ball Tree 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. 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.

The service had inclusive leaders at all levels who understood the context in which they delivered care and support and embodied the culture and values of the organisation. Leaders had the skills, knowledge and experience to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders were approachable and responded to concerns raised. Staff also told us leaders modelled the values of the service and some described the GP partners as ‘inspirational’. We saw the leadership team worked with other services in the primary care network and individuals were prepared to take on leadership roles in the locality and were engaged in the development of primary care services in the local area.

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

The service had established Freedom to Speak up arrangements with other services 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 service valued diversity in their workforce. They worked towards an inclusive and fair culture by promoting staff equality and equity.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support people return to work safely after a period of absence.

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 shared this securely with others when appropriate.

Leaders and managers supported staff, and all the staff we spoke with were clear on their individual roles and responsibilities. The service had established governance processes including effective clinical oversight and supervision of the wider team. The service contracted with a qualified person who carried out weekly monitoring and audit, for example, environmental inspections, and checked that any identified issues and risks had been addressed.

Staff could access all required policies and procedures. The service made use of technology to monitor risks and to prompt staff when actions were due. Managers held twice-weekly meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded actions arising from these meetings and ensured they shared these with staff. Staff took people’s confidentiality and information security seriously.

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.

Some members of the partnership and staff team also had leadership or designated roles with the primary care network and were actively involved in driving coordinated improvement across the area.

The service had developed effective working links with commissioners, community healthcare services, specialist health teams, schools and social services and invested time and effort in maintaining these links. For example, through regular meetings and casework reviews. They could demonstrate innovation, for example, by conducting work with local schools to address anxiety experienced by young people.

The service worked with other services in their primary care network to offer extended access, and flu and covid vaccination programmes. They had recruited people as volunteers to ensure the vaccination clinics ran smoothly. We spoke with some people who were involved, and they told us these events were well organised and effective.

The leaders were able to demonstrate their vision for effective ‘neighbourhood’ working to improve health outcomes alongside partner agencies and voluntary organisations and their strategy to put this into practice.

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.

The service had a quality improvement plan in place to help drive improvements in services. They had clearly identified risks to the service, for example, the need to make effective use of technology and triage while ensuring that people without digital access were not adversely affected by changes. The service had identified delays in carrying out some structured medication reviews and had implemented a recovery plan and risk mitigation. They took feedback seriously, for example, taking action when there was a pattern of complaints about an issue.

The service took advantage of pilot projects to test new ideas and improvements. Where time-limited projects were demonstrated to be beneficial for people, the service either secured longer-term funding or funded ongoing work itself.

The service was a training practice and was committed to providing high quality placements for new GPs and medical students. Feedback from trainees was positive about the quality of training and support.