The Cedars 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

Leaders and staff had a defined and shared vision. Their culture was founded on listening, learning and trust. Leaders were visible, knowledgeable and supportive and committed to helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

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. It also focused on engagement and understanding the needs and challenges of people and their communities. There were established and effective systems in place to promote adherence to the values of the organisation.

Staff told us they cared about their work and were committed to getting it right. They told us they were supported by managers and peers and had access to training and resources to develop within their roles.

Staff felt valued and heard, as they were encouraged to raise issues, contribute ideas, and have their achievements recognised.

The provider and management team understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They demonstrated that they had the experience, capacity, capability and integrity to ensure that the organisational vision could be delivered, and risks were well managed. The leaders promoted inclusive practices and had succession plans in place. They understood issues and priorities for the quality of services and were able to identify and access appropriate support and development in their role. They were alert to any examples of poor culture that may have affected the quality of people’s care and have a detrimental impact on staff.

Staff reported that their management team and colleagues demonstrated openness, honesty, and transparency in their interactions with each other and with patients.

Staff told us they were trusted to work with autonomy but had the support and assurance of clinical oversight.

The practice was in the process of appointing speak up champions for staff to approach if they felt unable to directly raise concerns with the management team. Staff also had access to external speak up champions if they felt more comfortable to do so. Concerns that were raised by staff were all recorded, investigated and responded to and any learning identified and shared to drive improvements.

Staff told us they valued their colleagues and the opportunities to support one another, shared learning and diversify their knowledge and skills base. Staff felt confident raising concerns or questions and welcomed the support of the Integrated Care Board (ICB). The ICB are NHS organisations responsible for planning health services for their local population.

There were established, effective and inclusive systems and processes in place to demonstrate the leaders had reviewed, considered and improved the culture of the practice. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff views and opinions were requested to inform the development of the service. There was a systemic review of policies and procedures to ensure they were reflective of best practice. Reasonable adjustments had been made in response to health and safety considerations.

The provider had established and effective governance, management and accountability arrangements. The practice manager had global oversight of activities to check on compliance and worked with the executive team to ensure this.

Lead clinicians oversaw risks such as safeguarding, medicine management and clinical practice. The provider conducted checks on individuals or collective prescribing behaviours to ensure adherence to safe practice.

Staff actively participated in contributing to governance systems and in overseeing and implementing safe practices. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider met with staff individually or collectively to assess and review performance. Lessons were learned from significant events, to help prevent similar incidents from reoccurring. Concerns raised in clinical meetings were actioned and resolved.

Staff and leaders operated with openness and transparency. They collaborated with all relevant external stakeholders and agencies. Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. Staff and leaders engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the service. They used these networks to identify new or innovative ideas that can lead to better outcomes for people.

Staff and leaders had a strong understanding of the importance of improvement and how to implement it effectively. They invested time and resources into listening to people’s experiences and made changes to improve the service. They referred to their patient participation group as critical friends and valued their experiences and contribution to improving the service.

There were established systems and processes to ensure staff learnt from previous adverse incidents, understood the risks, strengthened operating systems or improved people’s skills and knowledge to mitigate or remove the risks from re occurring.

There were established and known processes in place to identify and learn when things went wrong or could be improved both in the practices and locally within the Integrated Care Board. Leaders encouraged and welcomed staff to speak up, employing reflection and collective problem-solving.