Crown Street 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 practice 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. Staff were positive about the culture of the practice and told us they felt valued and supported by practice leaders. Leaders and staff told us there was an open culture, and leaders were approachable. We saw that policies were reviewed and updated regularly and staff had easy access to them. Leaders informed us they regularly communicated with outside bodies like the wider primary care network and local authority to ensure that the practice ran smoothly.

The practice 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 leaders modelled the values of the practice. 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.

The practice promoted 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 internally and externally to the service. The service fostered a positive culture where people felt they could speak up andstaff were aware of how to raise concerns.

The practice valued diversity in their workforce, they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The staff files reviewed showed equality and diversity training was completed. Staff had access to continual professional development, support, and mentorship.Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued.

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. The practice 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. The service had clear responsibilities, roles, systems of accountability, and good governance. They used these to manage and deliver good quality, treatment, support, and sustainable care. The service had a clear vision and oversight.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff had made adjustments to improve coordination of their service with community healthcare services. Theyworked withlocal charities toreduce health inequalities and provide people with more information about support available.

The partners were involved in the local Primary Care Network (PCN) and worked with other practices within the PCN to offer extended access. In addition, the partners are involved in GP training.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. They actively contribute to safe and effective practice. Leaders encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Training events are held at the practice, which included for example ‘lunch and learn’ sessions. The undertaking of staff, students and patient surveys encompassed a culture of learning and 94% of GP trainees rated the support and supervision a 4 or 5 out of 5.The practice had a range of audits and quality improvement projects. Projects were designed to improve performance, outcomes and patient experience.