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DCCS at Buckden and Little Paxton Surgeries Good

Inspection Summary

Overall summary & rating


Updated 25 April 2019

We carried out an announced comprehensive inspection at DCCS at Buckden and Little Paxton Surgeries as part of our inspection programme.

Dermatology Clinic Community Service LTD is an independent provider of a dermatology assessment, a minor surgery service, a vasectomy service, and a lymphedoema clinic. The service holds contracts with the local Clinical Commissioning Group (CCG) to deliver community services, closer to patient’s homes and avoid attendances at secondary care. They have been providing these services for approximately 16 years. They treat between 2,000 and 2,500 patients each year.

Dermatology Clinic Community Service LTD is registered with the Care Quality Commission to provide services at Buckden and Little Paxton Surgeries (a GP practice) with locations at Little Paxton (a branch site of Buckden and Little Paxton Surgeries), Warboys, St Ives in Huntingdon and in Hinchingbrook Hospital Treatment Centre. The services offered are dermatology outpatient opinions, minor surgery including biopsies, vasectomy, cryotherapy and lymphoedema.

The lead GP is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service proactively gained feedback from patients with regular reports compiled from the surveys conducted at each clinic. As part of our inspection we reviewed the results of the patient surveys that had been collected over the previous 12 months.

We received 36 Care Quality Commission comment cards, and all of these were wholly positive about the care and service and positive outcomes the patients had received. We spoke with five patients who reported that they had received excellent care in a timely and efficient manner and by staff who were caring and dedicated.

Our key findings were


  • We saw there was strong leadership within the service and the team worked together in a cohesive, supported, and open manner. Since our previous inspection there had been changes to the management team and a new manager started in December 2018.
  • There was an effective system in place for reporting and recording significant events.
  • Information about services and how to complain was available and easy to understand.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • All staff had received a Disclosure and Barring Service (DBS) check.
  • Risks to patients were assessed and the service provided evidence that further improvements to these systems were in progress.
  • The service held a comprehensive central register of policies and procedures which were in place to govern activity; staff were able to access these policies easily and all staff had signed each one. This ensured that the provider had oversight to manage the performance of the staff.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge, and experience to deliver effective care and treatment.
  • All patients said they were treated with compassion, dignity, and respect and they were involved in their care and decisions about their treatment.
  • The service had good facilities and was well equipped to treat patients and meet their needs.
  • The service proactively sought feedback from staff and patients, which it acted on. Regular surveys were undertaken and reports collated from the findings and action taken where required.

The areas where the provider should make improvements are:

  • Continue to embed the newly implemented systems and processes to ensure they are effective, including those relating to the management of training, safety alerts, health and safety and infection prevention and control.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 25 April 2019

  • We saw there were systems and processes to manage unintended or unexpected safety incidents. Staff we spoke with detailed how patients would receive reasonable support, detailed information and a verbal and written apology. They would be told about any actions to improve processes to prevent the same thing happening again.
  • The service had clearly defined and embedded systems, processes, and services in place to keep patients safe and safeguarded from abuse.
  • There were recruitment processes in place. All staff had received a Disclosure and Barring Service (DBS) check. Staff who acted as chaperones had been trained to undertake this role.
  • There were various risk assessments in place to ensure that patients and staff were kept safe. Some of these were being improved and we saw this was in progress; for example, a log for managing safety alerts and the use of external risk assessors to ensure good practice was maintained.

Safety systems and processes

The service had systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken and the practice policy was to undertake checks for all staff employed by the service.
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check. We reviewed three personnel files and found appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, training undertaken, qualifications and registration with the appropriate professional body.
  • We saw the service had identified three infection prevention and control leads to give clinical and managerial oversight and succession planning to ensure standards were met and maintain. The service had used a new IPC tool which was comprehensive and detailed with actions required and taken. The practice had a legionella risk assessment undertaken in February 2015 and were monitoring water temperatures, we saw evidence to show that in March 2019 the service had engaged an external provider to update this and to undertake the monthly water temperature monitoring.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. Equipment had been checked in July 2018. There were systems for safely managing healthcare waste.
  • The provider carried out environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them however some of these lacked detailed. We saw a comprehensive new risk register had been implemented and was being developed to identify risks, give a risk score and detail mitigating actions, controls and completion targets.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • Emergency medicines kept on site were appropriate and weekly checks were made on the expiry dates of medicines and equipment. Oxygen was available with children’s and adult’s masks and a defibrillator was on site.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • The GPs, nurse, and the healthcare assistants received regular clinical supervision in face to face sessions. The specialist nurse also demonstrated how they shared their experience and knowledge and learnt from a network of other nurses who specialised in the management of lymphoedema. The GPs and nurse had easy access to consultants in the local acute trust for advice and support.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. The service had been proactive and with the CCG had gained access to directly refer patients, including fast track referrals, to secondary care rather than through the patient’s own GP.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • During our inspection we noted that the service held, administered, and used medicines. The service provided NHS prescriptions and we saw these were stored and monitored appropriately. Information was passed to the patients GP to ensure they were aware of any medicines prescribed. The prescribing by the GPs was monitored by the CCG and by the accreditation service from the hospital dermatology service. We saw evidence that this was safety managed. We saw evidence where a significant event relating to medicines had occurred, a full investigation had taken place and changes to protocols and procedures were put in place to prevent it happening again.
  • The service did not hold stocks of controlled drugs (medicines that require extra checks and special storage because of their potential misuse).

Track record on safety and incidents

The service had a good safety record.

  • There were risk assessments in relation to safety issues; the practice told us they were reviewing these and, where it was good practice, using external providers to undertake and manage reviews and monitoring.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents. This included alerts from the Medicines and Healthcare Products Regulatory Agency. The practice had recently implemented a new tracking system for safety alerts ensuring all those relevant to the service were received, acted upon and monitored.

There were clear systems to manage unexpected or unintended safety incidents which would ensure;

  • The service gave affected people reasonable support, detailed information and a verbal and written apology.
  • They kept written records of correspondence.

There was an effective system in place for reporting and recording significant events.

  • Staff told us they would inform the management team of any incidents or significant events and there was a recording form available.
  • Staff told us they would discuss any significant events. They told us of changes made as a result of an incident or through recognised development or trend analysis of minor events. For example, for patients who are unable to see where a lesion was planned to be removed, for example on their back, a photograph would be taken using the patients mobile telephone so that they had a record of the where the lesion was removed.

The service held a system to record significant events which included details of investigations and actions taken because of the significant event. We saw the service had seven events recorded in the previous 12 months. The new management team had recently introduced new guidance to staff to ensure all events, even those considered minor and low risk were reported and analysed.



Updated 25 April 2019

  • Staff had the skills, knowledge, and experience to deliver effective care and treatment.
  • All members of staff were suitably trained to carry out their roles. We spoke with the dermatology consultant who attended the monthly dermatology clinic and clinical meetings to support and oversee the GPs undertaking assessments and treatment. They told us this was valuable as they had direct oversight whilst the patient was in the clinic and where appropriate could offer their expert opinion.
  • There was evidence of appraisals, induction processes and personal development plans for all staff which were specific to the services offered. We noted due to the change in managers, some staff were overdue their annual appraisal but dates had been planned to undertake these during April and May 2019.
  • The service ensured sharing of information with NHS GP services and general NHS hospital services when necessary and with the consent of the patient. There was a consent policy in place and we saw that written consent was always obtained.
  • The staff had carried out audits to monitor and improve their effectiveness in areas such as consent and effectiveness of treatment. These were used routinely to promote and develop the services further.

Effective needs assessment, care and treatment

  • The service assessed needs and delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines. Staff had access to guidelines from NICE and used this information to deliver care and treatment that met patients’ needs. Staff could give specific examples of updates relating to dermatology and lymphoedema.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing. Patients we spoke with commented that the staff always cared about their mental well-being when discussing the impact of their physical needs.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions in the records we viewed.
  • Staff assessed and managed patients’ pain where appropriate and information was given to patients to manage pain post procedure.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service held a register of all audits carried out which included timescales for further re-audit. They carried out audits such as audits of effectiveness and consent. For example, in January 2019, an audit was completed on basal cell carcinoma (BCC) management. Patient activity during July 2018 and November 2018 was used and the record of each patient was reviewed to check that excision margins were clear and histology type of BCC. The findings showed that 100% of clear margins were found, this showed an increase from 96% of a previous audit undertaken by the service and was above the national figure of 93 to 95% as quoted in the British Journal of dermatology. A re-audit was planned for January 2020 to ensure sustained performance.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and were up to date with revalidation. The service was undertaking a new accreditation for the GPwSI to become GPwER (GPs with enhanced roles).
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained and the management oversight of this had been recently improved as a detailed log of training with dates had been implemented. Here training which had been identified as due had been booked. Staff were encouraged and given opportunities to develop.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate.
  • Before providing treatment, doctors and nurses at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. A detailed check list was completed before any procedure carried out. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care. Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support. Post procedure information was given to patients in written form to ensure they did not have to remember all the information at one time.
  • Patients we spoke with told us of the support they had received in relation to help they had received to live a healthier life. For example, the specialist nurse who managed patients with lymphoedema was proactive in offering advice on weight and exercise to help patients increase their mobility and wellbeing.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance


  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately. We saw that written consent was always obtained and a copy of the information was given to the patient.



Updated 25 April 2019

  • Patients said they were treated with compassion, dignity, and respect and they were involved in decisions about their care and treatment.
  • We were assured that staff treated patients with kindness and respect, and maintained patient and information confidentiality. The service could evidence patient feedback from surveys undertaken and compliments received. All the surveys we saw, comments cards we received, and patients we spoke with reported positive experiences and outcomes.
  • The staff would ensure any patients who had longer waits before or after treatment due to delays such as patient transport was well looked after and made refreshments when required.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. We saw notices in the reception areas, including in languages other than English, informing patients this service was available.
  • Patients we spoke with and through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.



Updated 25 April 2019

  • Appointment times were available throughout the week and on Saturday mornings, making the service more accessible those patients who worked or relied on relatives or non-emergency ambulance services for transport.
  • The service provided video clips that could be accessed via their website to give patients easy access to information to enable them to understand the different procedures they offered.
  • The service had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand. At the time of our inspection, the service had not received any complaints.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. The service offered pre- bookable appointments. The electronic referral system into the service did not allow any booking for any patient aged under 16 years old. This ensured that all patients were suitable to be referred in. Staff triaged the referrals immediately to ensure that the referrer had included all information needed and that the reason for referral was appropriate for their services.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.
  • The service routinely undertook patients feedback. For example, a survey was undertaken for dermatology and skin surgery for a named clinician. 97% of patients strongly agreed and 3% of patients agreed that they were impressed with the service and the same percentages of patients would recommend the service to their family and friends.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised. Appointments and referrals were regularly monitored and where appropriate patients were brought forward to fill cancellation slots.
  • Patients reported that the appointment system was good and they were seen without delay.
  • Referrals and transfers to other services were undertaken in a timely way. The service had systems in place to monitor these to ensure patients received their appointments.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service informed other stakeholders or regulator bodies where appropriate.
  • There was a complaint policy and procedures in place. We looked at three complaints and found they have been well managed and in a timely way. The practice response included the details of how a patient could escalate their complaint if they were not happy with the response they had received from the service.

The service learned lessons from individual concerns and from analysis of trends. It acted as a result to improve the quality of care. For example, from a trend analysis the service recognised there was an increase in the number of patients who had not received a map and directions of how to find the service. The team discussed the system, found it was over complicated and made improvements. The map and directions were simplified and add to the back of the patient’s appointment letter.



Updated 25 April 2019

  • There was a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this. The business plan was reviewed on an annual basis.
  • There was a clear leadership structure and staff felt supported by management. The new manager had been in post since December 2018. There were a number of policies and procedures to govern activity and discussed and signed by all staff members.
  • An overarching governance framework supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. We saw that the new management team had started to further improve these systems to have clear oversight to monitor actions made and ensure they were effective.
  • We spoke with the dermatology consultant who oversaw and supported the GPs providing the treatment and they told us that the relationship between clinical team members was cohesive, supportive, and educational.
  • The lead GP and management team encouraged a culture of openness and honesty.
  • They proactively sought feedback from staff and patients and made changes to the service delivery as a result.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.
  • The GPs were proactive in sharing their experience and knowledge and often provided educational sessions to local GPs and GPs registrars. They held general talks with children in the local schools promoting a career as a doctor.
  • The staff regularly met for meetings such as clinical governance, dermatology team meetings, and other team meetings. Detailed minutes of these meetings were kept ensuring actions were followed through and completed. Regular agenda items including incidences however minor were discussed; patient feedback was also included.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners. And they monitored progress against delivery of the strategy. The CCG confirmed that they had a good relationship with the provider and had been holding discussions about future contracts.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.


The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. We saw examples where the service had undertaken reviews, shared learning with colleagues and external regulator bodies and made significant changes from that learning. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals although, due to the change in managers, some were overdue. The service had a plan and these were to be completed by May 2019. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. The new management team shared their plans to further improve their systems to ensure clear managerial and clinical oversight supported by an overarching risk register.
  • Staff were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Regular reviews of clinical decisions were undertaken by the team including the consultant from the local hospital who was easily available for advice and guidance. Leaders had oversight of incidents, and complaints. The oversight of safety alerts was being improved by the new manager with a detailed log which gave clarity to those alerts relevant to this service.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved involve patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, a survey was undertaken for dermatology and skin surgery for a named clinician. 97% of patients strongly agreed and 3% of patients agreed that they were impressed with the service and the same percentages would recommend the service to their family and friends.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings. We saw minutes of meetings that were held regularly and where input for staff had been recorded.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. Staff told us of the opportunities they had for example attending other meetings and forum for specialist nurses. All staff attended regular multi-disciplinary team meetings with other professionals such as the plastics department at the local hospital.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

There were systems to support improvement and innovative work, for example the service was discussing with the CCG and other colleagues about network and federation working and the IT developments for video consultations. Role development and succession planning was prioritised for the specialist nurses and GPs.