Thorntree 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 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 provider had a shared vision, strategy and culture, which staff showed a high awareness of. Culture was based on transparency, equity, engagement, and understanding the challenges and needs of people and communities.Leaders understood the challenges and worked with partner agencies to support people. There was a focus on continuity, accessibility, and reducing health inequalities.

Staff and leaders actively monitored and anticipated current and future risks to delivering the strategy, including relevant local factors. Equality, diversity and human rights approaches were embedded in the organisation and understood by all staff.

Staff demonstrated a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. Staff we spoke to felt positive about working at the practice and feedback from staff questionnaires was positive about their working environment and about their leaders. They described good teamwork and a service that was clear on its function to work in the best interests of patients, providing positive outcomes.

Staff described an open and supportive culture, where they felt empowered to speak up and raise concerns to help learn and improve. Protected learning time (PLT) was made available for staff training, and people were encouraged to further their learning.

The provider 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. Staff feedback was positive about leadership, with staff members we spoke with saying they felt supported by leaders.

Equality was embedded into many practice policies, such as the patient registration and chaperone policies. We saw 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.

We saw there were Freedom to Speak Up Guardians in place and supportive mechanisms for staff to raise concerns.Staff told us of an open, blame free, inclusive environment in which everyone could speak up. Staff knew how to raise issues, said they felt confident to do so and felt their concerns would be acted upon. Leaders demonstrated how they encouraged staff to raise concerns and promoted the value of doing so.This was underpinned by a Freedom to Speak Up policy.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by supporting equality and diversity for people who worked for them.

Reasonable adjustments were made to support staff to carry out their roles. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. The practice had an equality, diversity, and inclusion policy.

The provider had clear responsibilities, roles, and systems of accountability. There were established governance processes that were appropriate for the service. The provider used these to manage and deliver good quality, sustainable care, treatment and support. The service acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

Leaders made ongoing efforts to improve how services were delivered, using feedback from staff and patients to reduce risks and enhance care, and had a clear understanding of the challenges facing the provider.

All staff we spoke with were clear on their individual roles and responsibilities. Learning points were discussed at governance meetings and cascaded to staff.Managers met with staff regularly to complete appraisals and performance reviews, and staff felt these were supportive and useful processes. Staff and leaders monitored and anticipated current and future risks to delivering the strategy, including relevant local factors. Staff knew where to access all required policies and procedures and understood the importance of patient confidentiality and information security. There were arrangements for identifying, managing, and mitigating risks and a major incident plan was in place.

The provider understood their duty to collaborate and work in partnership, ensuring services ran smoothly for patients. We saw they collaborated for improvement across the wider practice group with their Federation and Primary Care Network, and participated in PCN audit activity. Staff made ongoing efforts to engage with safeguarding teams.

The practice had made efforts to establish a Patient Participation Group (PPG), however did not currently have one in place. The practice had encouraged patient involvement, including sending regular invitations, promoting the group on the website, and using text message invites. New patients were asked about joining the PPG at the point of registration, and posters were displayed throughout waiting areas.

The practice recognised difficulties some patients had in engaging, particularly with online services, and were participating in the Modern General Practice Improvement Programme to increase online access.

The provider encouraged continuous learning, innovation and improvement across the organisation and local system. Clinical staff had access to regular clinical supervision, protected learning time and annual appraisals, with a record maintained of their competencies.

We saw examples of completed audits which included improvements in care and outcomes for patients with UTIs and optimising HRT treatments. Audit subjects were identified through a number of routes including incidents, both internal and external, and special interest areas.

PLT sessions were used to discuss learning opportunities to enhance patient outcomes. These were highly valued by all staff.

Quality Improvement Plans were put in place and kept under review where there was identified need, such as in response to patient or staff surveys.