Eden 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 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. The service mission was ‘to continue to provide high-quality, compassionate and accessible care and to engage in partnership working to ensure the safeguarding of all our patients’. The goal was ‘to maintain an environment where the patient experience remains paramount. To make sure that medical care remains safe and effective for all users’. The vision was ‘To be part of a thriving general practice community, where our aim is to deliver healthcare that helps both individuals and the wider community to lead healthier lives’.

Feedback we received from staff regarding the culture within the practice was very positive. They told us it was a positive and friendly environment to work in, the culture was open, transparent, blame free and non-discriminatory and they enjoyed working there.

Leaders were aware of the challenge presented by the steady increase in the patient list size in relation to estates and staffing. Leaders have set targets for recruitment based on list size, which has resulted in the recruitment of additional clinical staff. Leaders continued to review staffing levels in relation to the practice list size.

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.

The leadership focused oncreating a work environment where all individuals felt valued, respected, and empowered in their roles and responsibilities, including the delivery of the service’s vision, strategy and culture. They embraced diversity, were sensitive to cultural difference, fostered a sense of belonging, and ensured equitable opportunities for all team members.

The leadership team had recently changed with the introduction of a new GP partner. Staff spoke positively about the leaders, that they were approachable and responded to any concerns raised.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements with the Integrated Care Board. Staff had access to a whistleblowing policy and were aware of how to raise concerns. Staff felt that they could speak up and were confident their voice would be heard and acted upon.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. We saw that any potential adjustments had been discussed and would be implemented as required to ensure all staff were valued.

The service 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 the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

However, action was required to ensure effective systems were in place for tracking prescription stationery.

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, although a formal system for regular audit consultations for non-medical prescribers was not in place. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures although a number required reviewing to include additional information or updating to ensure the information was up to date and accurate. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Staff took patient confidentiality and information security seriously.

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

Staff were encouraged and supported to attend monthly meetings and local forums which provided networking opportunities with other services within the Primary Care Network (PCN). Both the practice manager and lead practice nurse attended meetings, where they networked with staff from other local practices.

The service did not have a patient participation group (PPG) to support with suggestions for improvements based on feedback from people who used the service. Staff told us they had tried to encourage people to become member of the PPG but there had been no uptake. However, the service proactively sought feedback from people via the Friends and Family Test. The service received on average approximately 100 responses per month and the majority of feedback was positive.

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. The service used learning from significant events and complaints to continually improve the service they provided.

Staff participated in quality improvement work. For example, the introduction of the recall system to ensure all patient specific directions were up to date, a review of people with chronic obstructive pulmonary disease to ensure they were prescribed correct the inhalers in line with new guidance, and development of group consultations.

The service carried out audits linked to the clinical searches to ensure people were receiving the correct treatment for their condition.

The nursing team were planning to introduce group consultations for people with long-term conditions. Group consultations are a way for primary care practices to bring together individuals for support with long-term conditions, helping them to better manage their own health and share their experiences and learning. Group consultations can run for around 90 minutes and allow up to 12 participants to spend more time with their healthcare team and each other. The sessions are generally led by a facilitator, who could be any member of the practice team, with medical or therapeutic input from the appropriate clinicians or allied health professionals. The nursing team planned to implement group sessions initially for people with diabetes and evaluate the effectiveness of the service.