Eldene Surgery Also known as Dr Philip Gnana Asirvatham Bauliah

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

This is the first inspection for this service since its registration with CQC. 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 service 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 exceptional understanding of the challenges and the needs of people and their communities. Staff told us there was a positive and caring work culture and diversity was welcome at the service.

There was a strong, shared vision and culture, underpinned by a clear strategy and mission statement, which leaders communicated effectively to staff and the wider community through their website. Staff told us the culture within the service was friendly, compassionate, supportive and professional. The service promoted a culture of learning and development. Staff were offered opportunities to enhance their skills through leadership courses and specialist training, including asthma management and non-medical prescribing.

All staff had contributed to the development of the service vision and strategy, which was kept under review, and discussed in quarterly meetings. The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges, including the primary care network and local GP federation.

The service had exceptionally 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 always did so with integrity, openness and honesty.

People using the service were at the centre of the service’s work. Leaders valued staff wellbeing and supported them to maintain positive outcomes for those they cared for. They displayed high levels of credibility and consistently evidenced the successful delivery of their objectives throughout the inspection. We saw the leadership team worked with other services in the primary care network and were engaged in the development of primary care services within the local area.

There was a clear staffing structure, and staff understood their roles and responsibilities. They had access to line managers and senior leaders and felt able to seek advice and guidance when needed. Staff told us leaders were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service.

Staff described a culture that was open, supportive and caring. Leaders took time to support staff with both professional and personal matters. Leaders fostered a culture where staff felt valued and listened to, with staff reporting the leadership team was responsive to issues and implement action. The service actively sought staff feedback and demonstrated how it led to positive changes. For instance, following staff requests, a new outdoor seating area was created to enhance wellbeing and team connection.

An annual staff survey was completed, and the findings were shared openly with staff. Comparison with previous results demonstrated an improvement in staff satisfaction. For example, in 2023, 56% of staff agreed it was easy to learn from others, increasing to 100% in 2024. This reflected leaders’ proactive actions to develop staff skills and foster shared learning across the team through structured meetings and informal ‘lunch-and-learn’ sessions, based on feedback from the previous survey. Leaders intend to review progress in the next annual survey to ensure continued development and sustain a positive learning culture.

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

The service had established freedom to speak up arrangements with other services in the primary care network and GP federation, including a freedom to speak up guardian. Staff knew how to raise concerns, felt confident to do so, and believed their concerns would be acted upon.

Staff told us there was an ‘open door’ policy and leaders welcomed feedback for service improvements.The service had a zero-tolerance policy in relation to the abuse of staff, with systems to protect people and minimise the likelihood of reoccurrence.

The service 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 to support staff and people who use the service with different backgrounds and needs. This resulted in a workforce that was reflective of the community it served and was well-equipped to provide personalised care. There were no reported concerns relating to discrimination in the service, and staff told us diversity was welcome. Leaders upheld a zero-tolerance policy for discrimination, ensuring any concerns between staff or with those using the service were promptly addressed.

Leaders recognised the importance of career progression and actively promoted staff development, offering equal opportunities. For instance, 16 employees progressed within their roles at the service, including a health care assistant who moved into an assistant practitioner position and a receptionist who transitioned to a finance assistant role. Staff indicated that they felt valued, respected, and included, and noted that ongoing development opportunities were provided irrespective of their background.

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.Leaders demonstrated a clear commitment to respecting the cultural needs of staff. For example, working hours were adjusted during Ramadan to accommodate religious observance. Staff said this approach fostered a positive and inclusive workplace culture, where diversity was recognised and supported. As a result, staff felt valued and enabled to perform their roles effectively, contributing to the delivery of high-quality care.

Adjustments had been made to support staff in carrying out their roles and to ensure they felt valued. For example, reasonable adjustments were in place for staff to work flexibly around other commitments, such as childcare or other caring responsibilities. Leaders actively promoted staff wellbeing through social events, which helped to foster positive working relationships, encourage inclusivity, and contribute to a supportive workplace culture.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews. A range of audits was completed to monitor the quality of care and treatment provided. These included audits of prescribing, long-term condition management, minor surgery, and document processing. Findings from these audits were used to drive improvements and ensure safe, effective, and high-quality care.

The provider had established governance processes appropriate for their service. Staff could access all required policies and procedures and took confidentiality and information security seriously. A business continuity plan was in place, providing staff with clear guidance to follow in the event of system failures. This included detailed actions for managing emergencies such as power outages, environmental hazards, severe weather, and staff sickness. The service acknowledged the local council’s long-term housing development plans and anticipated population growth, incorporating these factors into workforce and succession planning.

Leaders held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Any actions arising from these meetings were recorded and shared with staff.

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

The provider worked with other services within their local primary care network and GP Federation to offer extended access, and flu and covid vaccination programmes. The service was aware of the needs of the local community and used this to improve outcomes for people by tailoring services to the local needs.A representative from the patient participation group (PPG) told us they had open lines of communication with service leaders, and their feedback was listened to and acted upon.

Staff worked proactively to improve coordination with community healthcare partners, including district nursing teams and secondary care, to ensure people received seamless, joined-up care. Leaders also promoted shared learning across the primary care network. For example, outcomes from an internal audit assessing the accuracy of the Heidi AI Scribe tool (an NHS-approved transcription tool used for consultations) were shared to support continuous learning, innovation, and improvement in practice.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

There was a business improvement plan in place to help drive improvements in services. This focussed on reducing GP appointment waiting times, increasing digital bookings, improving satisfaction of people who used the service and reduce staff absences. All staff were encouraged to put forward and test out new ways of working, and we saw examples of this during our inspection. The service promoted a strong culture of learning and reflection. Leaders and staff actively sought opportunities to improve care through research, collaboration, and the sharing of best practice. They valued the views of people and the community, using this feedback to drive meaningful and measurable improvement.

The service demonstrated collaborative work with the local primary care network (PCN) to support local health initiatives, including those related to learning disabilities, cancer, and immunisations. To support people with a cancer diagnosis and promote cancer awareness, the provider hosted a cancer roadshow event that was delivered across their PCN, which encompasses every service operated by the provider. All those registered at these services were invited to take part in the event. This was the second event of its kind, and feedback from the previous roadshow had been used to improve the day, including providing transport for those unable to attend. The event promoted the importance of cancer screening, recognising signs and symptoms, and accessing available support. Staff facilitated on-site booking of screening appointments during the event for people registered at the service, resulting in a 1% overall increase in cervical screening uptake among individuals aged 50 to 64 years, as well as a 1% overall increase in breast screening uptake. Clinicians were available to discuss concerns, and follow-up appointments were arranged as needed. The roadshow included talks from charities and specialists, and information leaflets were provided. Other PCNs attended the event to learn and implement similar initiatives for their populations.

The service effectively implemented a range of technological solutions to improve efficiency and enhance the quality of care. The Eclipse system supported medication safety by identifying individuals at higher risk of harm and prompting timely follow-up. The NHS-approved Heidi AI Scribe tool was introduced to transcribe consultations, with consent, allowing clinicians to focus on meaningful engagement during appointments. Feedback from people using the service had previously highlighted reduced interaction during mental health consultations. In response, leaders ensured this tool was used in these consultations to support clinicians in maintaining eye contact, engaging and building rapport while ensuring accurate and comprehensive record keeping.