Eastgate 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 79 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

All leaders we spoke with demonstrated their commitment to achieving their vision and strategy. Staff at all levels demonstrated an understanding of the practice vision and commitment to the values. Values included taking a person-centred approach, being compassionate and inclusive, and being empowered. We saw multiple examples of staff displaying these values. We saw examples of how they considered the vision and values in their practice, from their employment of new team members to how they appraised their staff.

Staff had contributed to the development of the practice vision and strategy. All staff who provided feedback to us confirmed that they knew the practice vision and strategy and were fully involved in implementing it.

During our site visit, we saw there was a strong team focus, and individual strengths were also highlighted. There was a positive and compassionate listening culture that focused on learning and development.

The service was aware of the projected increase in the local population. The service provides care to a younger, dynamic population. Leaders monitored their growth in list size, which influenced demand for services and access arrangements. The service had grown in list size from approximately 2,500 patients in 2019 to 8,800 patients currently. Leaders described how they were managing these demands by keeping ahead of the growth, reviewing their service and workforce models in their Primary Care Network (PCN) and sister practices, and working with partner agencies to address these challenges.

The service had exceptionally 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, and experience to lead effectively. There was a clear management structure, and leadership roles and areas of responsibility were well understood across the service. The leaders and managers we spoke with demonstrated a collaborative approach to leading the service and consistently displayed compassionate and inclusive leadership.

Leaders understood both local and national challenges across the health and social care system, including the risks and priorities affecting the quality and sustainability of the service. Leaders told us about the actions they had taken to address these challenges.

There were processes to manage performance, and leaders used data to compare the practice’s performance with similar local services to monitor and improve the quality of care.

Leaders led with openness and honesty and had created a strong staff culture through their leadership. They encouraged staff development, which contributed to high retention rates and low staff turnover. This supported long-term continuity of care for patients and demonstrated a positive team culture. Some staff told us they had been offered opportunities to move elsewhere but chose not to leave, as they valued the culture within the service.

Staff told us leaders in the practice were approachable and responsive to concerns. They were inclusive and worked with the team to achieve the highest level of patient care. Leaders had clear priorities and aims for the year ahead, which were shared with the team. There were regular team meetings and opportunities for catch-ups so staff could discuss queries and get advice to support their decision-making.

Staff at all levels referred to the culture within the service as a “family environment”, with support provided across the whole team. All team members we spoke with felt they were given opportunities to contribute fully to decisions irrespective of their position. The service had a ‘Suggestions Box’ that staff could use to post comments and suggestions, anonymously if they wished.

Staff gave examples of leaders listening and responding to suggestions and feedback. These included changes to staff rotas, adjustments to workload allocation, introducing additional opportunities for staff social engagement and wellbeing, and improvements to communication support for patients through the use of interpretation services. Staff also described how multidisciplinary discussions had led to improvements in medicines management processes.

Leaders organised ‘Practice Days’ where staff could discuss concerns, share information, and take part in wellbeing activities such as exercise, back care, and outdoor sessions. Events such as birthdays and staff achievements were recognised for example in the staff newsletters.

Staff told us they were clear about practice policies and procedures and who they could speak to if they had a question or concern. They spoke positively about leadership and said they felt supported and listened to. Feedback from staff consistently described leaders as accessible, responsive and supportive, and staff felt confident that concerns raised would be acted upon.

There was a strong emphasis on the safety and wellbeing of staff. Staff could access an Employee Assistance Programme, and information was displayed throughout the service on how to access this support.

The service fostered a positive culture where people felt they could speak up and that their voice would be heard.

The service had established Freedom to Speak Up arrangements and both a Whistleblowing Policy and a Freedom to Speak Up Policy. These included details for the practice’s Freedom to Speak Up Guardian, as well as information about organisations staff could contact outside of the service if they felt they needed to.

All staff had completed and were up-to-date with training, and staff we spoke to were all aware of how to raise concerns. Staff described an “open-door” culture where they felt supported, and they felt confident in raising any concerns.

The service valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them. There were high levels of satisfaction across all staff we spoke with.

The service demonstrated a strong commitment to equality, diversity and inclusion. Staff came from a range of backgrounds, cultures and nationalities and worked together in a respectful and inclusive environment. Staff told us they felt valued and supported regardless of their personal characteristics, and the practice promoted equality of opportunity for both male and female staff.

The service also actively embraced and celebrated diversity, including LGBTQ+ inclusion, which was visibly promoted through initiatives such as Rainbow Badges and Pride-themed displays and noticeboards. These measures helped create a welcoming, respectful and compassionate environment for both staff and patients, where differences were recognised, respected and valued.

There were systems in place to support workforce equality, diversity and inclusion, with an emphasis on the safety and wellbeing of staff. This included an equality and diversity policy, and all staff had completed training in equality and diversity.

Adjustments were made for individual staff to ensure they were able to carry out their role, for example, staff described how adjustments had been made to support them to continue working in view of their health needs.

The service had clear responsibilities, roles, systems of accountability, and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

There were generally effective governance systems in place to support the delivery of high-quality care and drive improvement. Leaders demonstrated good oversight of performance, with clear processes to monitor quality and manage risk. They maintained a service risk register, and had systems and processes for monitoring maintenance checks, staff training, recruitment, and general risk management.

However, we identified a number of isolated issues during the inspection, including a clerical error within risk assessment documentation, monitoring of room temperature medicines storage not being in line with service policy, some emergency medicines and equipment concerns and an IPC concern, which had not been identified through internal audit processes. These were addressed immediately by leaders.

Leaders responded promptly and positively to feedback, taking appropriate action to mitigate risk and providing assurance that improvements had been made. This demonstrated an open and transparent culture, with a clear willingness to learn and improve. Overall, these findings did not detract from the effectiveness of governance systems, and leaders demonstrated the capacity and commitment to maintain safe, high-quality, and sustainable care.

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 service maintained an appraisal tracker, and we saw that all staff consistently had annual appraisals. We reviewed a selection of staff records and saw evidence that appraisals had been undertaken in line with the service’s staff appraisal policy. Records demonstrated that appraisals included discussions about performance, objectives, and development needs.

The service had established governance processes that were appropriate for their service. Policy review panel meetings were held regularly. Practice policies were reviewed and improved or updated in line with the recommendations within them, or when the practice was aware of new guidance or had identified learning, for example from significant events or training. Staff could access all required policies and procedures.

There was a range of meetings with staff, during which they discussed clinical and non-clinical concerns and emerging risks. This included general team meetings, quality assurance meetings, clinical staff meetings, admin staff meetings, and safeguarding meetings. Managers clearly recorded any actions arising from these meetings and ensured they were shared with staff through meeting minutes. They also produced monthly clinical bulletins to share important updates, best practices, clinical guidance, and any other key developments with staff to support continuous learning and the delivery of safe, effective care.

The service had a culture of governance, reflection, and continuous quality improvement. There was a comprehensive programme of audits and quality improvement programmes, including patient safety and medicines optimisation audits and projects relating to long-term condition management. These audits resulted in improved performance for the practice and ultimately improved patient care.

The service had a business continuity plan. The plan outlined what staff should consider and the actions to take if there was a major incident or disruption to the service, such as loss of computer or telephone systems; loss of utilities such as gas, electricity, and water; fire or flood; pandemic; staff incapacity; or terrorist attack.

Leaders shared a comprehensive plan to support succession, workforce continuity, and the sustainability of the service. The approach was a management team set-up that was not dependent on one individual. The service was already a training practice for physician associates; healthcare professionals who assess, diagnose and help manage patients under a doctor's supervision. They also told us they were working towards becoming a GP training practice, which would enable the service to train qualified doctors to become GPs under the supervision of experienced GPs. This was intended to support workforce development and retention.

Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, and services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders and staff worked closely with community teams, social care services, specialist professionals including Macmillan nurses, and the local authority to deliver coordinated, person-centred care. These partnerships supported people with complex needs, including those requiring palliative and end-of-life care, and helped ensure care was coordinated and responsive to individual needs.

The service also collaborated with local social workers, health visitors, and council staff to promote childhood immunisations. Information created by the practice was shared through schools, crèches, playgroups, and council buildings to help raise awareness among local families to help improve engagement with families and reduce barriers to accessing preventative healthcare.

The service was part of a Primary Care Network (PCN) which included its sister practice and a third related local practice. Shared leadership arrangements supported a coordinated approach to service delivery, governance, and quality improvement across the network. The service worked with the other practices within the PCN to develop and deliver services tailored to the needs of the local population while sharing learning, resources, and best practice across the network.

The service actively engaged with local communities and had taken the lead in organising healthcare events in community settings, including local Gurdwaras and churches. There were a range of presenters including from specialist organisations. These events were designed to improve access to healthcare information, advice, and support within the community and were well attended, with some events becoming fully booked. Staff also participated in other community events, including community days and Pride events, promoting health awareness and improving access to healthcare services.

Leaders described a range of outreach initiatives including support for people experiencing homelessness, and residents living in local asylum accommodation.

The service worked closely with local care homes to support the delivery of care for residents. This included regular multidisciplinary input from a range of practice clinicians, including routine visits to care home residents and medication reviews. Care home representatives described generally positive working relationships and recognised the commitment of clinicians to resident care. They also identified opportunities to improve communication, coordination, and timeliness in some aspects of service delivery.

Leaders worked in partnership with the Patient Participation Group (PPG) to gather feedback, share updates, and communicate information more widely across the local community. Regular meetings were held on a quarterly basis. PPG representatives provided positive feedback about the service's engagement and described improvements that had been made in response to feedback, including increasing awareness of access to some specialist areas.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Leaders promoted a positive learning culture in which staff at all levels were encouraged and supported to develop their skills, knowledge, and competence. Learning was shared effectively and used to make improvements across the service. There were well-established systems to learn and reflect from incidents, updates, and staff and patient feedback.

The continual development of staff skills, competence and knowledge was recognised as integral to ensuring high quality, safe care, improved access and sustainability. Staff were actively supported to acquire new skills, develop and share best practice. Staff told us they felt valued and supported and spoke positively about the development opportunities available to them.

We saw numerous examples of how the service encouraged learning and development amongst all staff groups. Staff described a culture where learning and career progression were actively encouraged and supported. Some staff had expanded their clinical skills and taken on specialist responsibilities after completing additional training, while others had progressed from administrative roles into management and leadership positions. Staff were confident the practice would support them to pursue further development opportunities aligned with their interests and career goals.

Staff consistently spoke positively about the culture of the team, describing a supportive environment where colleagues worked well together and wellbeing was prioritised. This contributed positively to the delivery of patient care and supported staff engagement in improvement activities.

Leaders encouraged staff to share ideas and identify opportunities for improvement, helping to foster a culture where continuous learning and service development were valued. There were mechanisms in place, including a staff suggestion box, to encourage involvement in improvement activities. Staff described examples of ideas that had been successfully implemented, including changes to appointment processes.

Leaders demonstrated a commitment to improving care both within and beyond the practice. The Lead GP also worked with the Integrated Care Board and was the lead GP for safeguarding across the local area, contributing to wider improvement and the sharing of learning across the system. This role enabled the service to influence safeguarding practice and share learning across the local health system.

Innovation and improvement work was driven by an understanding of the needs of people registered at the practice. There was an established and extensive programme of quality improvement activity. We reviewed numerous examples of clinical audits and quality improvement projects undertaken by the service, with evidence that findings had been used to drive improvements in clinical practice. Some of these improvements were reflected in the outcomes of our clinical searches, which identified no concerns requiring further action. The service also made effective use of PCN-funded resources, including the clinical pharmacist team, to support audit activity and safer prescribing practices.