Southway 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 assessed all quality statements in the well-led key question. At our last assessment we rated this key question as requires improvement. This was due to a lack of staff meetings, a lack of communication around significant events and a lack of process to monitor high risk medicine management. At this assessment we rated the key question as good. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, and enabled staff to 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 meet people’s needs 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 practice had a shared vision, strategy and culture. Staff feedback regarding the culture at the practice was positive. Staff were clear about the vision for the practice and understood the need for another partner. Staff told us there was an open-door policy where they could access and speak openly to leaders. Staff were encouraged to keep their knowledge and skills up to date in line with continued professional development requirements to support the practice.

There was a business development plan and succession planning documents which showed the practice routinely reviewed their patient services to promote improvement in service provision. The practice were actively recruiting for another GP partner to support their business development and succession plans and build resilience in the service. Weekly manager meetings took place and new or emerging risk was discussed and shared with staff.

The practice had inclusive leaders at all levels. They 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. Leaders included staff in their planning for the future. Staff told us they were well supported by leaders who were visible and approachable. They told us leaders supported them in professional and personal matters and they felt valued and listened to.

We saw the leadership team worked with other practices in the Primary Care Network (PCN) and were engaged in the development of primary care services within the local area. A PCN is a group of GP practices working closely together, aligned to other health and social care staff and organisations, providing integrated services to their local population.

The practice fostered a culture where staff felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns and tell us the importance of a Freedom to Speak up Guardian (FTSUG). There was a Freedom to Speak up policy which clearly indicated who staff were to contact and how to contact them. These included name, email, telephone number and address of the FTSUG. Staff felt confident to raise any concerns with their managers and leaders. The practice had established Freedom to Speak up arrangements with other practices in the primary care network.

The practice valued diversity in their workforce. They were working towards an inclusive and fair culture by improving equality and equity for people who worked for them. We saw an example of workplace adjustments to supports different needs.

Staff gave examples of reasonable adjustments the practice had made to support them both at work and in personal circumstances. There were processes to support staff wellbeing which were accessible to all staff. All staff had completed mandatory training around Equality, Diversity and Inclusion to help them understand about protected characteristics, bullying and harassment.

The practice 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 information about risk, performance and outcomes, and shared this securely with others when appropriate. Leaders and managers supported staff. All staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals. However, performance reviews were not always documented. The practice had since told us they will ensure this will be put into place.

Regular meetings were held to discuss clinical concerns, review incidents and share learning. Managers clearly recorded any actions arising from these meetings and ensured they shared these with relevant staff.

The practice had established effective governance processes which supported service provision. Policies and procedures used by the practice were accessible to staff and were regularly reviewed to ensure they contained relevant information. Managers clearly recorded and securely saved any actions arising from meetings regarding the practice and ensured these were shared with staff. Staff took patient confidentiality and information security seriously. All staff had completed relevant training around Information Governance.

Staff felt there was an open and transparent collaboration between the practice and patients. Systems and processes were in place to ensure referrals to other services were made and had been acted upon. The practice worked with other service providers in their area and shared information and learning to drive improvements for people that used their services when needed. The provider worked with the other GP practices within their PCN to offer extended access for flu and Covid vaccination programmes. Staff had made adjustments to improve coordination of their practice with community healthcare services including through established weekly meetings with their PCN.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. Staff were encouraged to develop their skill set to enable them to take on new roles, responsibilities and further their careers. Since the last inspection the provider had implemented many changes to ensure they were delivering safe and effective care. For example, all team meetings were arranged, monitoring and reviewing long term conditions (LTC) were taking place regularly and a new triage and appointment system had been put into place. The practice encouraged staff to put forward ideas for new ways of working and they were given time and resources to develop their skills.