Triangle 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 Requires Improvement. At this assessment, the rating has changed to Good.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

Since the last inspection, the practice had made improvements and is no longer in breach of regulation 12 (Safe care and treatment).

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 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.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. They were trying hard to move to a bigger and new location.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. 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.

At the last inspection we did not see evidence of a succession plan in place. At this inspection the practice told us they were continuing to try and recruit a salaried GP or another partner but were currently only using locum GPs.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff said there were no barriers to speaking up and their views were listened to and acted upon. This aligned with the management approach of being actively engaged with staff to seek their views.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

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.

We saw all staff (clinical and non-clinical) had completed equality and diversity training.

Policies and procedures to promote diversity and equality were in place. The recruitment policy stated the practice would ensure that its recruitment process was free from discrimination and followed the principles and ethos of the Equality Act 2010.

We did not receive any negative feedback from practice staff regarding equality, diversity and inclusion. Staff said they felt supported by management and worked as part of a team.

At the previous inspection, the practice had governance processes and risk management systems that operated ineffectively. During this inspection we found that the practice had robust governance processes in place.

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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff we spoke with knew who the relevant lead person was for areas such as safeguarding, infection control and significant events monitoring.

Managers met with staff regularly to complete appraisals and performance reviews. 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. The practice had daily briefing catch ups and practice meetings were held monthly. There were weekly meetings for the administrative staff and the operations manager, to enable collaboration on ideas and share experiences.

They also had quarterly Integrated Care Board (ICB) child safeguarding meeting. We reviewed a sample of minutes from all the meetings for the previous 3 months.

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 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 extended access, and flu and covid vaccination programmes. 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 was working with the patient participation group (PPG), they met every 3 months and were trying to recruit more members. The PPG feedback patients appreciated that 4 of the GPs were Urdu speaking. Response times to deal with online requests was better and appointments were more readily available.

The practice had monthly meetings with the Chief Executive of the call handling service, where they discussed themes and trends.

The practice was trying to arrange talks with the local Mosque, to aid in the engagement with patients to educate and discuss lifestyle change.

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 practice provided many opportunities for staff to develop and learn. One person gave the following feedback “The practice provides excellent training and development opportunities, ensuring that I feel confident and well-equipped in my role. Whether it's through mentorship, access to courses, or day-to-day guidance, I've consistently felt encouraged to expand my skills and knowledge”.

The practice had a quality improvement plan in place to help drive improvements in services. They also had an action plan which reviewed data from the friends and family patient survey also national GP Patient survey, this focussed on improving phone access, website and NHS app access. All staff were encouraged to put forward and test out new ways of working.

The practice told us they were most proud of their Health Care Assistant (HCA) as she had exceeded their annual target of completing (111 checks) and had completed 168 (152%) of their annual target of NHS health checks.

Due to the high population of patients speaking Urdu the practice told us they intended to send out messages via Accurx (a messaging system used to communicate with patients) in Urdu. The practice told us they were going to install tablets in reception, which patients could use in reception and get support from staff.