Sheet Street 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

The service now had clear and effective governance processes that operated consistently throughout the service. The provider now had effective processes to identify risks that affected the service and systems and processes to record, monitor, manage and regularly review such risks. The provider had a clear strategy and vision for the future and progress against delivery was monitored. Leaders were approachable and knowledgeable about issues that affected the service and promoted a positive and open culture. Roles and responsibilities within the service were clearly defined and succession plans were in place. Leaders engaged with partners to share information and learn from them to improve the quality of services for patients and the wider community.

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 had developed a clear vision for the future supported by values and a mission statement. Leaders explained how they had protected the time and resources necessary to ensure a structured development process in collaboration with service users and external partners. Staff we spoke with shared the vision, felt consulted in its development and understood its importance in ensuring the service remained inclusive for all and met the challenges faced by general practice in the future. Staff also spoke of how important it was for the practice to modernise and continue to effectively support patients while doing so. Systems and processes existed to ensure a positive, collaborative and compassionate culture continued. Staff and leaders we spoke with explained how equality and diversity were a priority for the practice. Leaders prioritised transparency and learning to ensure safe, high-quality compassionate care was delivered.

Staff told us how approachable and visible leaders and management in all roles were. Staff had confidence that the leadership team had the right skills, knowledge and experience to lead the practice effectively and compassionately. Leaders told us of changes made since the last inspection which included significant changes to the management structure. For example, the role of practice manager had been split into 2 roles: business and operations manager. Leaders reported they found this had been a highly positive change. Staff felt leaders were open, honest and always demonstrated integrity. We found clear governance processes to define roles and responsibilities. The practice had completed succession planning and was able to show how it both identified talented staff and offered development to progress the careers of all staff. Leaders had become involved with initiatives run by partners and had been asked to become ambassadors to promote the benefits of the initiative.

All staff we spoke with had clear understandings about the Freedom to Speak Up (FTSU) processes within the practice. Staff felt there was an open and transparent culture within the practice that encouraged people to raise concerns and staff did not fear any negative repercussions if they spoke up. Staff were confident that if they raised a concern they would be listened to. Leaders had a clearly considered rationale for appointing two members of staff that were not in the management team as internal FTSU guardians. The provider had a clear FTSU policy which provided staff with details of the key organisations and contacts relevant to the speaking up agenda both nationally and locally. We saw evidence during our visit of how the practice promoted a culture of openness and supported staff to speak up and share concerns at the earliest opportunity.

We spoke with a range of staff and all told us they felt there was a fair and inclusive workplace within the service and none had any concerns about inequalities. Leaders confirmed they reviewed the culture within the organisation and provided examples of reasonable adjustments which had been made for staff. All staff and leaders spoken with confirmed there was zero tolerance for any forms of bullying, harassment or discrimination within the practice. Policies and processes reviewed confirmed the practices’ commitment to equality, diversity and inclusion. Many policies referenced the fact the impact of the policy had been considered from an equality, diversity and human rights perspective. Strategic documents further evidenced the practice’s commitment to equality due to establishing the ambition of an inclusive practice for staff and patients and to having no inequalities for any patient wishing to access care and treatment.

Governance processes had improved since the last inspection. Leaders explained the changes which had been made to ensure risks were identified in a timely manner and once known, were managed and monitored. Staffs’ feedback demonstrated processes were now clear and understood. All staff spoken with confirmed they could access policies and procedures from a centralised shared drive system, which gave them confidence that in the absence of a manager or leadership they could find information. Leaders explained they now had improved systems and processes which provided oversight of risk and performance and how these were monitored to assure them the quality of the service was maintained and improved. We found processes existed to ensure roles were clearly defined and the distribution of responsibilities among the leadership team had been considered carefully. Business continuity arrangements existed and had been enacted several times recently. On each occasion, learning had been taken and changes made to improve the processes if they were required in the future. Risks were recorded on a risk register which was monitored regularly and where appropriate risks had associated control measures. A programme of regular meetings across all staff groups was established to ensure effective communication throughout the practice.

The practice provided examples of how they had shared information with partners and key stakeholders to promote health initiatives and share good practice in the community. We saw evidence from partners which commended the quality of the promotional material and the proactivity of the practice for running a health campaign. Leaders explained how a member of staff in the management team had become a NHS ambassador for computer systems and the modernisation of primary care. The practice had taken part in the GP Improvement Programme (GPIP) to help it modernise and improve access for patients. Having completed the GPIP, the practice had become ambassadors for the programme locally and had provided feedback to partners and local stakeholders about the benefits the practice had found. We also saw an example of how the practice’s own clinical auditing had identified an area where performance could be improved and the practice shared this with partners to help them improve their own performance and outcomes for patients.

All staff we spoke with confirmed that the practice was focused on learning and continuous improvement. Staff felt encouraged to raise ideas for improvements to processes and reported they always received feedback and an explanation if something was not possible. Leaders spoke positively about the benefits of taking part in the GPIP and explained how this had led to a process called segmentation being introduced. This categorised patients into groups depending on their needs and helped the practice to optimise care by reducing incorrectly allocated appointments and ensuring people were seen at the right time, by the right person and in the right place. We found evidence that the practice had established processes to gather feedback from staff and patients and that when changes were made or new systems were introduced, their effectiveness was evaluated and if necessary further changes were made.