Sandy 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 inspection, we rated this key question as good. At this inspection, 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 clear and embedded shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders invested in learning and development for staff to assist them in best practice and demonstrated the importance of staff wellbeing to support them in maintaining positive outcomes for people using the service.

Staff were aware of the practice vision and strategy, which was displayed in the practice and on the practice website and kept under review. Feedback from staff and the Patient Participation Group representative was very positive about the culture within the practice. They told us there was an open and transparent culture and they were encouraged and supported to raise any issues and suggestions for improvement.

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.

Values were actively integrated into daily practice, establishing an open and respectful culture. Staff told us leaders in the practice was approachable and responded to any concerns raised. They spoke positively about the leadership team and reported the practice was a great place to work where leaders and staff were both friendly and supportive. This was also reflected in the recent staff survey undertaken.

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.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns and were encouraged to approach practice management or any of the GP partners with any concerns. They also had access to a designated member of staff at the local Integrated Care Board (ICB).

The service 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. Staff had completed training in equality and diversity and were aware of supporting people with protected characteristics. No concerns were raised with regards to workforce equality. Adjustments had been made to ensure all staff were valued, for example adjustments to accommodate flexible working arrangements where appropriate.

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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff we spoke with told us leaders encouraged an open-door policy and were always responsive and available to provide support. Staff told us the practice manager worked across the provider’s other sites, but they were accessible by phone. They also had access to a management assistant. Clinical meetings were held to discuss current guidelines and quality improvement.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, in addition to completing appraisals and performance reviews. 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 shared information and learning with partners and collaborated for improvement.

The practice had recently worked with other practices within the Rugeley and Great Haywood Primary Care Network (PCN) to strengthen access to services ahead of the seasonal pressures. The practice had participated in the PCN’s Winter Ready event which was jointly coordinated by social prescribers and practice managers. A range of local organisations attended including community pharmacies to help promote services such as the Pharmacy First, Everyone Health Staffordshire, Inspiring Healthy Lifestyles, Midland Partnership Foundation Trust and other support agencies. Practice staff and members of the Patient Participation Group (PPG) also attended to provide information, signposting and support. This demonstrated the practice’s commitment to community engagement and to working with system partners to improve access and patient awareness of preventative services.

The practice worked with their PCN to offer extended access. They also facilitated face to face protected learning time (PLT) sessions for staff at 23 local practices.

The practice had an established and active Patient Participation Group (PPG) which provided membership from patients at Sandy Lane Surgery and their sister practices. The group had a Chair and Vice Chair and meetings were structured and held quarterly. Any concerns raised by patients were addressed promptly outside of these meetings. Meetings were held in 2 halves with the practice manager and GP partners attending in the latter half to share updates and any practice news. Meetings were recorded and included identified actions and were uploaded to the practice website. The PPG Chair told us leaders actively encouraged feedback to improve patient care and services, but they would welcome better use of the PPG as a testing bed for changes. The service provided care and treatment to patients registered in 6 care homes. Feedback from a care home representative was positive, they were satisfied with the service provided and valued the positive working relationship they had with the practice.

The practice told us they had worked in partnership with other organisations to improve the quality of the service since they were initially rated as requiring improvement by the Care Quality Commission (CQC) in 2022. Quality visits to the practice had been undertaken by the Local Integrated Care board (ICB). They reported engagement with the practice was positive and leaders reached out to them if they needed any support or direction. The ICB told us the practice had also worked with the GP support team completing a standard level framework toolkit to help identify what they were doing well and what they could improve on.

The practice used learning from significant events and complaints to continually improve the service they provided. An annual analysis of complaints and significant events was undertaken to reflect and drive improvements.

A range of clinical audits had also been undertaken as part of their quality assurance to improve patient care. The practice performance was shared and discussed with staff at meetings held.

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 practice remained a training practice for GP registrars to gain experience and higher qualifications in general practice and family medicine.

Leaders told us they planned to work with local secondary schools and provide educational sessions to raise awareness of healthy diet, smoking and childhood pregnancies.

Since the last inspection the practice had hosted a Veteran event inviting all registered veterans at Sandy Lane Surgery and their sister practice. The event provided an opportunity to explain the services available to veterans and included local organisations promoting their support roles. This event demonstrated the practice’s commitment to community engagement, targeted support for specific population groups, and collaborative working with local partners to improve access and patient experience. A Winter ready event had also been hosted along with the PCN and PPG promoting local services and promoting self-care.