Catherine House 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. The service 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.

At our last assessment in April 2022, we rated this key question as Requires Improvement. We served a Requirement Notice for breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 17: Good Governance.

During our responsive follow up assessment in September 2022, we assessed that improvements had been made but we did not re-rate the service.

At this assessment, the rating has changed. This key question has been rated as Good.

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.

Leaders and the service management team detailed a clear vision and values for the service. This was shared with staff. Staff were aware of and understood the vision, values and strategy and their role in achieving them.We found that there was a clear vision and set of values, which the service acted on. The service had a realistic strategy and supporting business plans to achieve priorities. The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population. The provider monitored progress against delivery of the strategy.

The service was aware of health inequalities and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment, support and embodied the culture and values of their workforce and service. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us that managers were visible and approachable and that they worked closely with staff and others to make sure they prioritised compassionate and inclusive management leadership.

There were clear lines of responsibility to support capable leadership. The service had job descriptions for all staff and had ensured staff were aware of their roles and responsibilities.

We saw the leadership team worked with other practices in the primary care network (a group of GP practices working together, alongside other health and social care providers, to deliver more coordinated and comprehensive care to a defined local population) 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 service had established Freedom to Speak up arrangements with other practices in the primary care network.

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. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued. For example, we saw adjustments to support staff working flexibly.

At our last assessment in April 2022, we found overall governance arrangements did not provide sufficient assurance of ongoing resilience and evidence of effective management of risks as an expanding practice; processes for managing risks, issues and performance were not fully embedded, and the service did not provide assurance that all risks were mitigated as far as reasonably practicable.

During this assessment, the service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always act 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. Managers met with staff regularly to complete appraisals and performance reviews.

The provider and service management team had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. GP partners and 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 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 provider worked with other practices within their primary care network to offer extended access, flu and covid vaccination programmes.

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 service had a quality improvement plan to help drive improvements in services. This focussed on the appointment system, medicine prescribing and improving uptake rates for childhood immunisations.