Cornhill 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 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 meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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, engagement, and understanding challenges and the needs of people and their communities.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and had increased its boundary to accommodate people moving into new housing developments. Leaders had applied for funding to build an extension to include 4 new clinic rooms.

The service had 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 did so with integrity,openness and honesty.

Staff told us leaders in the practice were very approachable and responded to any concerns raised. They told us leaders modelled the values of the practice. Staff felt valued and well supported in their work by both leaders. 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 service promoted a positive culture where people felt able to speak up and be heard.

The practice had established Freedom to Speak Up arrangements with other practices in the primary care network, enabling staff to raise concerns with someone outside their own practice. Staff in these roles had received appropriate training. Staff were aware of how to raise concerns, and we saw examples where the arrangements had been used effectively.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Career development opportunities were offered to staff such as management apprenticeships.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff flexible working hours were in place.

The service did not always have clear responsibilities, roles, systems of accountability or good governance.We found in some area’s paperwork was not adequately managed. This did not relate to patient care but could affect the smooth operation of the practice. For example,human resource files were disorganised, and some evidence could not be located during the onsite visit. Summarising of new patient notes had a small backlog of files which needed to be completed and some files were waiting for scanning on to the electronic system. Safeguarding training had not been completed to the correct level for some staff although staff demonstrated a good understanding of what was expected of them.It was not easy to see how learning from incidents had taken place in the way files were organised. Leaders had taken immediate action to rectify the concerns raised and had provided CQC with a plan of how this will be achieved.

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 provider had established governance processes which were appropriate for their service relating to audits of patient care.This included audits for the prescribing of hormone replacement therapy (HRT). Staff could access all required policies and procedures. 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 service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to ensure services provided were meeting the needs of their local communities. Staff had built good working relationships with community nurses and nurses from the local hospice.

The practice sponsored a local walking group for older people in the local community. The group had been running for several years and was well attended. Members of the patient participation group (PPG) said how much the group appreciated the support. The practice was veteran accredited, and staff were working with the local Royal British Legion and the Primary Care Network (PCN) funded social prescriber to see if the same model could be used for a veteran’s group.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice.

The practice had a quality improvement plan in place to help drive improvements in services. This focused on areas such as the appointment system, staff training and building improvements. All staff were encouraged to put forward and test out new ways of working and felt they would be listened to.