The Pines 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. We found there was an inclusive and positive culture of continuous learning and improvement shared by all staff. There were effective, well embedded governance systems that aimed to manage risks and keep people safe. Leaders had a clear business plan and gathered feedback and information about risks, performance and outcomes which they used effectively to make decisions about future developments. Leaders were visible, knowledgeable and supportive, 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. This key question has been rated as good.

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. There was a practice mission statement reflecting on the practice’s belief in maintaining their long-standing tradition of a practice team and an environment which was welcoming, caring and accessible for all their patients.

The provider 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 understanding of the challenges and the needs of people and their communities. Staff teams met regularly to discuss challenges, collaborate as a team, share learning and develop cohesion between their roles and support the practice vision. Leaders promoted a positive, compassionate, listening culture that supported trust and understanding between staff and patients using the service. Wellness was seen by managers as a leadership responsibility, and it was a shared value for all staff.

The practice had processes and information to manage current and future performance. The information used in performance management ensured that the quality of care delivered was accurate, valid, reliable, timely and relevant.

The practice 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, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Leaders had an inspiring shared purpose, striving to deliver and motivate staff to succeed. There were high levels of staff satisfaction. Staff were proud to work at the practice and spoke highly of the culture. There were consistently high levels of staff engagement. Staff at all levels were encouraged to raise concerns and feedback. Staff retention was a high priority; there were several members of staff who had worked at the practice for over 30 years and many staff for over 8 years.

There was a continual development of staff skills, competence and knowledge was recognised as integral to ensuring high quality safe care, improved access and service sustainability. Staff were proactively supported to acquire new skills, develop and share best practice. There was strong feedback from staff including reflections on where they had been developed. The practice could demonstrate where they had strengthened capacity for succession for the future and invested in supporting leadership competency. There was a clear strategic business plan that leaders regularly reviewed and worked towards.

Staff were encouraged to develop and we saw multiple examples of this. For example, a healthcare assistant who had trained as a nurse associate, a care navigator trained as a phlebotomist and nurses trained in chronic disease management and prescribing. As a result of linking training and development with quality and innovation the practice could give examples where they had expanded or strengthened services, for example, improved access through care navigation training. 

Staff told us leaders in the practice were approachable, responded to any concerns raised and modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had a Freedom to Speak up policy that included relevant information about how to contact the Freedom to Speak up Guardian. Staff knew who the Freedom to Speak up Guardian was. Staff told us they were able to raise concerns to each other and leaders at the practice, they told us their concerns were valued and acted upon appropriately.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. There were robust, fair and transparent recruitment policies and procedures. All staff had completed equality and diversity training. Adjustments had been made to ensure all staff were valued. Staff felt included and leaders had a structure in place to ensure staff had equal opportunities for career development.

The practice had clear responsibilities, roles, systems of accountability and good governance. Leaders 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.

Governance systems were comprehensive, effective and well-embedded into the delivery of the service. There was a strong framework of accountability to monitor performance and risk, leading to demonstrable quality improvements to the service. There was effective use of risk registers and logs, including a comprehensive risk register for the entire service. This was regularly reviewed, updated and actions taken in a timely manner to monitor and reduce identified risks.

Audits we reviewed and results of our clinical searches further demonstrated that the governance and performance managements arrangements were working effectively to support best practice service delivery. Training delivery was of a consistently high standard, ensuring that adopted practices were aligned with best practice standards in multiple areas including infection prevention and control (IPC) and medicines safety.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders and managers drove an awareness of positive accountability, support and sustainable improvement across the organisation. They met with staff regularly to complete appraisals and performance reviews.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. All policies and procedures we reviewed were written in house style. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The use of effective governance systems and risk registers supported leaders to actively anticipate current and future performance and risks to the quality of the service, therefore supporting sustainability, business continuity and strategic development. For example, there was a clear strategic plan and leaders were able to discuss how this would support the extensive planned expansion of the local population in the future. This included significant expansion of the existing building and staffing. The practice could demonstrate where they had strengthened capacity for succession for the future. 

The provider clearly understood and carried out 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.

The provider worked with other practices within their primary care network (PCN) to offer extended access, develop improved ways of working and share resources to support the local population. Staff worked with community healthcare services, including through established meetings centred on the care of people who were housebound or had long term conditions.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice supported all residents at 2 local nursing homes, 2 local residential homes, 3 homes for people with learning disabilities and 1 children’s home. In addition, the practice supported some residents in a further 10 homes supporting patients with learning disabilities, mental health concerns and brain injuries.

There was a well-established patient participation group (PPG) which was supportive of the practice in driving improvements. The PPG acted as a channel for communication between the local community and the practice. The practice was actively promoting further recruitment to the PPG.

The practice team proactively supported local and national charities, through regular fund raising and food bank collections. Leaders advised these efforts provided additional fulfilment for staff, embedded the practice in the community and supported team cohesion.

The service focused on continuous learning, innovation and improvement across the organisation and local system. There was a continual development of staff skills. Competence and knowledge were recognised as integral to ensuring high quality safe care, improved access and service sustainability. Staff were proactively supported to acquire new skills, develop and share best practice. Learning from significant events and complaints were seen as an opportunity to continuously drive improvement across the service. There was a strong programme of clinical audit to support improvement.