De Beauvoir 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 found that the service’s leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. Governance processes were effective, staff felt supported by leaders who were visible and approachable. The provider had systems to manage current and future performance and risks to the quality of the service and had taken steps to make service improvements.

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 was guided by a shared vision, strategy, and culture rooted in transparency, equity, equality, and human rights, and committed to diversity, inclusion, meaningful engagement, and a deep understanding of the challenges and needs of individuals and their communities.

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.

Due to the open-door policies and robust communication channels, leaders were aware of issues arising outside their direct line of responsibility. The service had policies and procedures which supported a learning culture. The provider offered apologies to people, learned lessons from individual concerns and complaints, and took action to improve the quality of care. Staff had clear roles and responsibilities and had shown flexibility to meet patients' needs.

The service fostered a positive culture where people felt they could speak up and that their voice would be heard. Staff we spoke with felt that leaders were approachable, listened, and acted in response to matters raised. They told us they did not fear repercussions for speaking up.

There were processes in place to encourage staff to speak up. The provider had maintained a whistleblowing policy with guidance for staff on how to contact external organisations if they were not confident raising concerns internally. Processes had also ensured that when things went wrong, people had received an apology and had been informed of actions taken to prevent recurrence.

The service valued diversity in its workforce. Leaders worked towards an inclusive and fair culture and staff told us they work well as a team and supported one another.

Staff and leaders had clear responsibilities, roles, systems of accountability, and good governance. These had been used to manage and deliver high-quality, sustainable care, treatment, and support. Leaders had acted on the best available information about risks, performance, and outcomes, and had 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. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes appropriate for the service. Staff had access to all required policies and procedures.Managers held regular meetings with staff to discuss clinical concerns and emerging risks. Any actions arising from these meetings had been clearly recorded and shared with staff. Staff had taken patient confidentiality and information security seriously, supported by relevant policies and procedures.

The service had understood its duty to collaborate and work in partnership so that services worked seamlessly for people. Staff and leaders had engaged with people and partners to share learning, which had resulted in continuous service improvements, such as attending primary care network meetings and participating in local community activities.

The service had focused on continuous learning, innovation and improvement across the organisation and local system. We observed evidence of shared learning and staff involvement at all levels. Leaders had regularly reviewed the service’s assurance systems. Clinical audits and quality improvement processes had positively impacted the quality of the service.

The leadership team had managed clinical supervision and documented all supervision meetings. The service had maintained an established patient participation group. Feedback had been positive, and the group had felt involved and listened to. They met regularly and had been able to submit ideas.

The provider had implemented a range of quality improvement initiatives to drive service improvements, with a focus on the appointment system. All staff had been encouraged to propose and test new ways of working. We saw that the leadership team had worked with other GP practices in the primary care network and had supported their staff through external training opportunities.