Southfield Way 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

There had been changes in the leadership team following the appointment of a new practice manager. Most staff told us leaders were approachable, supportive and responded to their concerns. Leaders understood the context in which the service delivered care, treatment and support. Leaders and staff had a shared vision and culture. Staff were encouraged and supported to develop and had clear roles and responsibilities. Most staff felt supported to give feedback. A Patient Participation Group (PPG) had been formed and positive working relationships developed. Leaders worked with the local community to deliver the best possible care although feedback from 1 care home representative suggested improvements were needed to improve the care and experience their residents received from the practice. Quality improvement activity was carried out through ongoing audits. However these required a clear purpose including actions and outcomes to demonstrate improvement in outcomes for people using the service.

Since the last assessment, the practice had made improvements and is no longer in breach of regulation 17 good governance but continues to be in breach of regulation 12 safe care and treatment. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 68 (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. The practice vision was to be a leading healthcare practice that delivered exceptional, patient-centred care, promoting the health and wellbeing of the community through innovation, compassion and collaboration. The mission statement, aims and objectives were detailed in the statement of purpose. Most staff considered the practice had a clear vision for the future. The provider told us they promoted a culture where staff felt empowered to suggest improvements and innovations in governance processes and that there was open and transparent communication between leaders and staff. Feedback we received from staff about the culture of the practice was mainly positive, but we were told the atmosphere had not always been positive between staff members following a recent situation and communication could be improved. Staff understood the challenges and the needs of people and their communities.

Since the last assessment there had been a change in leadership following the appointment of a new practice manager in in January 2024. Leaders understood the context in which the service delivered care, treatment and support. Most staff told us leaders were approachable and responded to concerns raised although some staff felt communication could be improved. Some staff had left the practice since the last inspection. The representative of the Patient Participation Group (PPG) spoke highly of the current leadership team and told us significant changes had been made to improve the service and patient experiences. They considered leaders were inclusive, open and required praise for the work they had achieved. They told us the lead GP had attended a PPG meeting to thank the group for their comments, suggestions and contributions.

Leaders worked with other practices in the primary care network and were engaged in the development of primary care services within the local area. Leaders had considered succession planning and were looking to appoint a female GP to strengthen the clinical team. Following our site visit the provider told us they had appointed an assistant practice manager to provide cover for the practice manager and reception during annual leave.

Most staff told us they felt supported by leaders and considered their views were listened to and acted upon. They told us concerns, especially in relation to patient care, would be welcomed and they were aware of how to whistle blow. Staff had access to a speak up policy and Freedom to Speak up posters were displayed in the practice, but not all staff were aware of who to contact internally and outside of the service should they need to raise concerns. The provider told us that the practice manager was being trained as the internal guardian as per the National Guardian’s Office training programme and staff had been advised of contacts during a recent meeting held.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

A staff member told us the GP encouraged them to do the best they could, and they had regular catch-up sessions to raise anything they needed to. Another member of staff told us they were given additional time for extra tasks and that annual leave was approved when they requested it.

Policies and procedures to promote diversity and equality were in place and staff had received equality and diversity training to support them in their work.

Following changes to the leadership team, the provider had identified and established defined roles, responsibilities and systems of accountability to ensure governance processes were monitored and updated regularly. We found the governance processes implemented since the last assessment had improved but were not yet fully embedded into practice or effective. Most staff told us they felt supported by leaders who were visible and approachable. Staff demonstrated an understanding of their individual roles and responsibilities. Leaders met with staff to complete annual appraisals and performance reviews. Staff could access policies and procedures. Practice meetings were held with staff, during which they discussed concerns and any emerging risks. Actions arising from these meetings were recorded and shared with staff.

Leaders did not always take patient confidentiality and information security seriously. Two events in relation to the breach of patient personal data had been recorded but not reported to the Information Commissioner’s Office (ICO). In 1 case there was no record that the patient had been made aware of the breach in line with duty of candour. In addition we found omissions in the effective oversight of emergency medicines, prescription security, patient group directions, staff recruitment practices, record keeping and the management of complaints.

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. The provider had developed a partnership working and collaboration policy with aims to build strong, effective partnerships to enhance patient care and service delivery. They worked with other practices within their Primary Care Network (PCN) to offer extended access and share experiences and learn from other practices that had successfully implemented governance improvements.

Since the last assessment, the practice had formed a Patient Participation Group (PPG). The PPG representative told us they had developed a positive working relationship with leaders, who proactively engaged with the group. They considered the views of the PPG were listened to and acted upon. They shared examples of improvements that had made to improve patient experience. They told us the lead GP had attended a meeting with the group and thanked members for their contributions.

There were processes in place to work in partnership with key organisations to support the provision of care and joined up working. The practice provided a GP service to 4 local care homes. We received feedback from 2 representatives. One representative told us they would welcome more face-to-face clinical time and was generally neutral in their opinion of the service provided. Another representative considered in addition to the weekly telephone contact currently provided, face-to-face clinical time was also needed, at least once a month. They also shared concerns in relation to some communication challenges and advised us these had been escalated, and a meeting had taken place. The local Integrated Care Board (ICB) have continued to undertake visits to the practice and discussions had been held regarding leadership and capacity.

The provider told us they participated in quality improvement initiatives to drive ongoing enhancements in governance and care delivery including the General Practice Improvement Programme (GPIP) in conjunction with the Royal College of General Practitioners to enhance patient experience and satisfaction and reduce pressure on the practice team.

The practice had a quality improvement plan in place to help drive improvements in services. They told us they had applied for a practice improvement grant to create a new clinical room to enhance the services offered. They were looking to recruit a female GP via the additional roles reimbursement scheme (ARRS), a program that provides funding to primary care networks (PCNs) to recruit and support roles within the team). They also planned to redecorate the whole surgery, provide more drop-in sessions with the care co-ordinator and develop the care plan process for patients registered as carers. Improvements had also been made to accessing appointments to improve patient experience.