Porters Avenue Doctors 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 71 (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 was part of a larger organisation and therefore maintained a shared vision, strategy and culture. They aimed to provide a primary care service that reduced health inequalities and eases the burden on secondary care. The service aimed to collaborate with local healthcare, social care and voluntary sectors to help patients and the wider community.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The service created a ‘people and culture plan’ which aimed to enhance the service’s mission, vision and values. Key initiatives and actions included amending the induction programme to include more service values, formalising a staff ambassador programme, redesigning appraisal conversations and maintaining a regular HR presence in the practice.

The practice was aware of low scores from the National GP patient survey and acted on it to increase patient satisfaction levels. This ranged from in-house surveys, staff training, monthly reviews of performance data and gathering patient feedback.

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. There was clinical oversight provided by the organisation’s clinical management team, who ensured processes and policies were implemented into looking after patients. They worked in collaboration with the management team at the service to lead an effective team who had the skills, knowledge, experience and credibility to perform effectively.

We spoke with a range of staff who told us leaders in the practice was approachable and responded to any concerns raised. The leadership team emphasised a no-blame, learning environment to encourage staff to raise issues and share observations. 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.

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

Staff we spoke with felt leaders were approachable, listened, and acted in response to matters raised. Processes had also ensured that when things went wrong, people had received an apology and had been informed of actions taken to prevent recurrence.

The practice had established internal Freedom to Speak up arrangements within the service. However, at the time of the inspection, the service did not identify an external, independent Freedom to Speak Up Guardian. The service told us they were in the process of arranging further Freedom to Speak up arrangements with the appointment of an Independent Guardian who worked within the organisation but outside of the practice.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The practice planned to implement the Workforce Race Equality Standard and Workforce Disability Equality Standard into their policies. The practice published a gender pay gap statement annually to address any gender pay inequalities.

Policies and procedures to promote diversity and equality were in place, with equality and diversity training completed. Adjustments had been made to ensure all staff were valued. We found no concerns reported regarding workforce equality.

The service had clear responsibilities, roles, systems of accountability and good governance. The service had a clinical governance team to provide clinical and medical oversight, as well as different governance leads, such as a dedicated HR team.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. 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, 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.

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 practices within their primary care network to offer services for their patient population. For example, they recognised there was a need for a physiotherapist within the community and through collaboration, practices within the PCN increased physiotherapy services. The practice work with their GP federation to provide additional services to patients, such as spirometry.

Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The practice acknowledged they did not, at the time of the inspection, have an active Patient Participation Group (PPG). They told us they had regularly invited patients to PPG meetings but did not have a large enough attendance to form a PPG. The practice recognised the importance of establishing a PPG; they had displayed recruitment posters in the reception area and practice website, assigned a PPG lead to drive recruitment and introduced sign-up sheets at reception. After the assessment, the practice informed us they invited approximately 300 patients for a PPG meeting held online to maximise attendance, with two patients attending the meeting.

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. They actively contribute to safe, effective practice and research.

The provider had implemented a range of quality improvement programmes to drive service improvements, which included a review of the appointment and triaging system, as well as quality improvement audits to increase the quality of clinical care provided to patients.