Crabbs Cross 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 was well managed. Leaders and staff were clear about their roles and responsibilities. Since the last inspection systems were being put in place to support good governance. Leaders demonstrated that they understood the challenges to quality and sustainability and had taken actions necessary to address them.

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.

Staff said the practice had a clear vision for the future. Staff told us they thought the culture of the service had improved and leaders were open, transparents and supportive.

The practice had a vision, aims and strategy policy in place. Leaders ensured this was developed and discussed with staff so the vision for the practice was shared by everyone.

Staff told us they felt supported by the management team. Staff reported managers were visible and approachable. Leaders spoke with us about the improvements the practice had undertaken since our previous inspection. There had been changes in management, administrative staff and an improved telephone system and appointment booking process. Leaders told us they were alert to any examples of poor culture which might affect the quality of people’s care and have a detrimental impact on staff. They told us they would address this quickly and we saw evidence this was the case in the way they addressed concerns and complaints.

Leaders encouraged professional development and staff confirmed this. For example, staff in reception had received additional training to help them support and signpost patients. The practice had an appropriate recruitment policy in place. Staff recruitment files demonstrated the policy was followed, and good practice was used during recruitment.

Staff were aware of how to speak up and felt confident they would be able to raise concerns. They had confidence any concerns raised would be addressed. Leaders investigated sensitively and confidentially, and lessons were learnt, shared, and acted upon. Complaints and concerns were fully investigated and when something went wrong, people received a sincere and timely apology.

The practice encouraged a positive culture where people felt they could speak up. The practice had their own Freedom to Speak Up procedure and an integrated care board Freedom to Speak Up policy. Freedom to Speak Up is a way of ensuring staff can raise concerns, know they will be listened to and issues raised are acted upon.

All staff had completed training in equality, diversity, and inclusion. Staff confirmed they understood the policy and how it related to the Equality Act 2010 and people with protected characteristics such as age, gender, religion, or disability.

The practice had an equality, diversity, and inclusion policy. The policy contained details of how the practice was committed to both eliminating discrimination and encouraging diversity amongst the workforce, patients, and service users.

Staff told us they had opportunity to attend meetings and had protected time for non-direct patient duties for example stock control and training. Staff told us they found the meetings beneficial, and it allowed them opportunities to discuss clinical issues.

There were effective arrangements for identifying, managing, and mitigating risks. A business continuity plan was in place to ensure staff could continue to provide a service if there were issues with the building or staffing levels. Governance in the practice had improved with a change of management leadership. There was evidence of quality assurance activity and clinical audits. For example, they had participated in the General Practice Improvement Programme to evaluate and improve how patients accessed the practice. The practice had a clear management structure in place with designated staff members who acted as leads for clinical and non-clinical areas. The practice used digital services securely and effectively and conformed to relevant digital and information security standards. There were clear arrangements in place for the availability, integrity and confidentiality of data, records, and data management systems.

The practice had a small patient participation group who they consulted with when changes were being made. Plans were in place to increase the membership of this group going forward to ensure a wider view from the community was gathered. People said they were happy with the way the practice engaged with them and were able to refer them to other services.

The practice used NHS Friends and Family feedback, compliments, and complaints to assess people’s views or experiences of the practice. The practice had engaged with hard-to-reach groups. For example, they had links with a service providing health care using a mobile van who provided clinics to patients who lived in areas or communities where it was more difficult for patients to attend the surgery or use telephone appointments. The practice also had access to interpreter services and their system had an alerts option and this flags where appropriate for example, language and communication barriers.

The practice worked closed with the local primary care network and the integrated care board who spoke positively about the practice.

Staff told us the practice held regular meetings and changes and actions were communicated by email. As the practice was small, unscheduled meetings often took place to share information. The practice manager followed these up with emails confirming the discussion had taken place.

Staff told us there is a focus on continuous learning and improvement. For example, the appointment system was changed to improve access following patient feedback.

Leaders focused on continuous learning and improvement. They had a significant event policy in place, and we saw evidence of a documented significant event. The practice had taken part in a quality improvement activity to improve access and made improvements to their website. As a result of this, the practice improved their care navigation which led to an increase in physiotherapist referrals.