The Randolph 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 and at this inspection the rating has remained the same. There were clear responsibilities, roles, and systems of accountability to support good governance and management. Leaders were visible, knowledgeable, and supportive, helping staff develop in their roles. Staff felt supported to give feedback and said they were treated equally, free from bullying or harassment.

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 practice had a 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. We saw that policies were reviewed and updated regularly, and staff had easy access to them. Leaders informed us they regularly communicated with outside bodies like the wider PCN and Integrated Care Board (ICB) to ensure that the practice ran smoothly.

The practice had inclusive leaders 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.

Leaders and staff told us there was an open culture, and leaders were approachable and responded to any concerns raised. The practice offered flexible working arrangements where possible. The leadership team worked with other practices in the organisation and PCN and were engaged in the development of primary care services within the local area. Staff we spoke with were aware of those with lead roles in the practice.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistle blowing policy in place and staff we spoke with were aware of the arrangements in place. The practice had established Freedom to Speak up arrangements on an organisational scale external to the practice and staff were aware of this. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to a positive effect.

The practice 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 and staff had completed equality and diversity training. Adjustments had been made to ensure all staff were valued.

The practice 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.

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. The practice 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, 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 practice understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The practice worked with other practices to offer extended access. Staff had made adjustments to improve coordination of their service with community healthcare services, including through established meetings centred on the care of those at higher risk of hospital admission. The practice was involved in meetings with other healthcare providers to develop the way care was delivered.

The practice 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. They actively contribute to safe, effective practice. The practice had a quality improvement plan in place to help drive improvements in services. This focussed on access, patient satisfaction, childhood immunisations and cervical screening data monitoring.