Park Lane 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 has remained 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 shared vision, strategy and culture. The mission statement was ‘To provide caring, high quality and safe healthcare to our practice population in a responsive and accessible manner’. The vision for the service was ‘To be the leading practice in Derby and Derbyshire for patient experience and clinical care’. This was underpinned by the values of quality, innovation, integrity and compassion. Staff were aware of the mission statement, which was displayed around the practice.

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 list size in relation to estates and staffing. They had developed a 10-year building improvement plan, with the purpose of modernising the building and optimising space, in conjunction with a 3-year practice staff plan, to strengthen workforce capacity.

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, experience and credibility to lead effectively. They always 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 practices 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 service had a stable and experienced leadership team. Staff spoke positively about the leaders, that they were approachable and responded to any concerns raised. The service had dedicated wellbeing champions, who supported formal and informal chats with staff. 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.

We saw leaders challenged examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. Leaders shared action taken, which included written communication to all staff regarding fostering a positive work culture and respectful environment and expected behaviours.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of who the freedom to speak up guardian was and what whistle blowing was. The service had established Freedom to Speak up arrangements with the Integrated Care Board. Staff were aware of how to whistle blow and who the Freedom to Speak Up Guardian was and what their role was in supporting staff. 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 work 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 senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support staff were in place.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate. However, action was required to ensure effective systems were in place for logging prescription stationery, checking expiry dates of consumables, and oversight of non-medical prescribers prescribing and consultations.

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 of prescribing and 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 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. 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 clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared 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 Networks (PCN). One of the GP partners was the cancer lead for the local PCN. They developed a bimonthly cancer bulletin focussing on a specific disease, which provided information, guidance, details of any educational events and local projects as well as a focus on health inequalities where appropriate. These newsletters were shared with all services within the PCN.

Staff from the service had attended a local playgroup to raise childhood vaccination awareness. The session provided an opportunity to demystify the childhood vaccination schedule and an opportunity for parents to ask questions.

The service was supported by a proactive Patient Participation Group (PPG). The PPG acted as a conduit for communication between the local community and the service. Members of the PPG were active with the local community and linked with local community groups. The practice, in collaboration with the PPG, had hosted and supported a series of talks related to health topics and living well. For example, menopause, skin cancer and pigment lesion clinics, local first responders, Macmillan End of Life Care, Darley Abbey Community Association, Derby City Council and Derby County Community Trust. These events were either held at the practice or in local community halls and were open to all. Events were advertised on the website, in the waiting room and on local community notice boards.

The practice worked in partnership with key organisations and agencies to support the provision of care and joined up working. Regular community support team meeting were held to share information about people in need of additional support.

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 was a teaching practice for medical students. Systems were in place to support students during their placements. The service used learning from significant events and complaints to continually improve the service they provided.

Staff participated in quality improvement work and the findings were shared across all staff teams. For example, dermatology referrals and two week wait cancer referrals.