Thorpe-le-Soken 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 practice 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 75 (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. We were told by staff this was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding the challenges and needs of people and their communities. We were told the practice kept communicating with an open-door policy and accessibility to management. They also told us that they offered services based on needs not want’s.

The practice was aware of the projected increase in their local population and was working with their primary care network (PCN) practices to address future challenges and needs. This was seen in the PCN meeting notes.

Staff told us the practice 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. Evidence was provided to show leaders had the skills, knowledge, experience and credibility to lead effectively.

Staff we spoke with told us leaders at the practice were approachable and responded to concerns when they were raised. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services for their local area. GP leaders told us they had good communications with the other GP partners in their primary care network (PCN) and discussed local improvement work.

Staff told us there was a positive culture at the practice where staff and people using the practice services could speak up and felt their voice would be heard.

The practice had established ‘Freedom to Speak up’ arrangements. Staff knew how to raise concerns, and we saw examples that the arrangements in place had led to a positive outcome. The practice leaders told us that all staff had a designated line manager and were encouraged to speak up. Practice staff had access to a designated human resources company for support.

The practice told us they valued diversity in their workforce to meet their population needs. Policies and procedures to promote diversity and equality were in place. We saw senior leaders understood concerns relating to discrimination. Although not currently needed we were told adjustments could be made to ensure all staff were valued, and support staff needs with flexibility to meet their home life balance.

The service had clear responsibilities, roles, systems of accountability and good governance. This was used to deliver effectively monitored quality, sustainable care, treatment and support. Staff acted on the best-practice information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and the staff members we spoke with were clear about their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The practice had established governance processes that were appropriate for their service delivery. Staff told us they could access all the required policies and procedures to support them at work. During the regular practice meetings with staff, the leaders discussed any concerns and emerging risks. Actions arising from meetings were documented and shared with staff.

Staff told us they took patient confidentiality and information security seriously.

The practice understood their duty to collaborate and work in partnership with other health and care providers, to ensure services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The practice worked with other practices in their primary care network (PCN) to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through meetings focused on the care of those at higher risk of hospital admission and at the end of their lives.

Staff told us the practice was focused on continuous learning, innovation and improvement across both the practice and the local area primary care system.

The practice had an important plan to help drive improvements in services delivered.Practice improvement work had been focused on improving the access to services.

Leaders at the practice told us they had designed their work times and patterns to meet the patients’ and staff needs for a good work and home life balance. The dispensary had a delivery service to support and improve dispensing patient needs.

A separate building on the practice site had been built for staff to unwind and have their lunch away from the practice building to improve staff morale.

Leaders told us they were exploring ways to increase the clinical space at the branch site and install a lift to be inclusive for all patients.

The audits that had been carried out to explore improvement work at the practice were; to ensure the ACURIX system was benefiting patients, a ‘did not attend’ (DNA) an appointment for long term condition management to recall patients and mitigate the risk of them not receiving appropriate and effective monitoring, a recalls and review of all DNA’s, an efficiency review of discharge letters to ensure all treatment and medicine changes are recorded. This audit work had been undertaken and was informing the practice improvement plan.