King Edward Road 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 leadership, management and governance supported the delivery of high-quality, person-centred care, promoted learning and innovation, and fostered an open and inclusive culture. We found an inclusive and positive culture of continuous learning and improvement shared across the practice. Effective and well-established governance systems were in place to manage risks, monitor performance and help keep people safe. Leaders had a clear vision for the service and used feedback, performance data and information about risks and outcomes to inform decision-making and service development. Leaders were visible, knowledgeable and supportive, and encouraged staff development. Staff felt able to raise concerns, provide feedback and contribute to improvements. They told us they were treated fairly and with respect, free from bullying, harassment or discrimination. Staff understood their roles and responsibilities and were supported to carry them out effectively. This key question has been rated as good.

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 leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. 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. There was a practice vision statement reflecting on the practice’s core values of teaching, innovation, quality care and safety.

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 care, treatment and support were delivered and embodied the values and culture of the organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively and demonstrated integrity, openness and honesty in their approach.

Leaders had an inspiring, shared purpose, striving to deliver and motivate staff to succeed. There were high levels of staff satisfaction. Leaders undertook regular staff surveys to promote staff voice. 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. We saw adjustments had been made to ensure all staff had the ability to be included in meetings through changes in meeting days/times and online access to meetings through digital software. Staff retention was a high priority; there were several members of staff who had worked at the practice for over 20 years and many staff for over 8 years.

As part of our assessment, we received feedback from 24 members of staff who were all positive about their work life. Staff told us leaders in the practice were approachable, responded to any concerns raised and modelled the values of the practice. Staff spoke positively about the culture within the practice and described high levels of support and job satisfaction. They were proud to work for the organisation.

The continuous development of staff skills, knowledge and competence was recognised as integral to delivering high-quality, safe and sustainable care. Staff were proactively supported to develop their skills, undertake new responsibilities and share best practice. Feedback from staff demonstrated they valued the opportunities available to them and could describe how they had developed in their roles. We saw several examples of career progression and professional development, including a member of staff who had joined as a healthcare assistant and had been accepted onto an independent prescribing course.

We saw the leadership team worked collaboratively with other practices within the Primary Care Network (PCN) and was actively involved in the development of primary care services across 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 effective and well-embedded into the delivery of the service. 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, including systems to support effective medicines optimisation and review of patients with long term conditions. They responded positively and quickly to feedback received through the course of this assessment. The practice demonstrated a commitment to continuous improvement through its investment in digital practice management software. Leaders had invested both financial resources and considerable time to fully embed the system and maximise its use across the practice. 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.

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.

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 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 residents at 5 local residential care homes and 2 neurological rehabilitation centres. Feedback received from these services was positive.

There was an 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 service demonstrated a strong commitment to continuous learning, innovation and improvement both within the practice and across the wider health system. The practice was a recognised training practice and supported GP registrars undertaking specialist training to become GPs. All qualified GPs were qualified GP trainers, which had enabled them to support an increasing number of trainees.

There was evidence to demonstrate advanced use of IT systems and in-house programming to support safe and effective care delivery. For example, we saw digital systems had been developed which not only supported quick identification of vulnerable patients but also provided instant access to priority information.

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.