High Oak Surgery

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• 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.

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 and learning, and engagement was actively reviewed to support continuous improvement.

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 fostered a culture of positivity, compassion, and active listening, with a strong emphasis on promoting equality and diversity. They showed awareness of the challenges and changing needs of the local population.As the Trust transitioned into provision of primary care, it recognised the need to adapt its approach for general practice. As part of the transition to delivering primary care services, some Trust processes were under review to reflect these changes.

The Trust recognised that general practice required a different approach than secondary care and Trust processes were under review to ensure they better reflected the needs and structure of primary care.

Staff listened to patients’ needs, complaints and suggestions and showed an understanding of equality, diversity and human rights in providing safe, compassionate care for the patient population. Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care.

The service 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. They did so with integrity, openness and honesty. There were areas of accountability at both The Trust and practice level which included quality, governance, operational and clinical leadership.

Staff told us leaders in the practice were 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.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns.

Leaders encouraged the reporting of incidents to identify ways in which the practice could continually improve. All staff had undertaken equality and diversity training.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place.

The service had policies and procedures in place to promote diversity, equality, and safe recruitment practices. It actively valued diversity within its workforce and worked towards fostering an inclusive and fair culture by improving equality and equity for all staff.

Key policies included those relating to recruitment, equality and diversity, bullying and harassment, and grievance procedures. Staff were supported through regular appraisals, one to one meetings, coaching and mentoring, clinical supervision, and revalidation.

A structured induction process was in place for newly appointed staff at both Trust and practice level, ensuring they were well supported from the outset. As part of mandatory training, all staff had completed equality and diversity training, reinforcing the service’s commitment to inclusive practice.

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 acted 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 had established governance processes, however some required adapting for the 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 provider had established systems to effectively manage clinical and operational risks, while also supporting ongoing improvements in service quality and patient outcomes. 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 shared information and learning with partners and collaborate for improvement.

Leaders collaborated with other practices in their Primary Care Network (PCN) to deliver extended access. The practice had multidisciplinary meetings to discuss and improve outcomes of complex patients.

The practice continued to promote continuous improvement by acting on complaints and feedback received.The practice had a Patient Participation Group (PPG) that operated within the Primary Care Network (PCN) however we found that no meetings had taken place in the past 12 months.

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 sought to improve the service and focused on improving health inequalities. Quality improvement audits were carried out regularly. There were regular clinical meetings to discuss patient needs and best practice.

Systems for assessing the quality of the service and outcomes for patients were in place. The provider also worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.