Neston 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 assessed seven quality statements from this key question. At our last assessment, we rated this key question as good. The rating remains good following this assessment.

Leadership, management and governance ensured high-quality, person-centred care and treatment was provided. We found the provider had clear and effective governance processes, which supported the safe delivery of care.

Leaders clearly demonstrated capability, compassion and inclusiveness.

Workforce equality was a priority for the leadership team. Staff understood their roles and responsibilities and those of other members of the team and lines of accountability were clear. Staff felt well supported in their role.

Staff were provided with information about speaking up and they told us they felt confident to raise issues and that if they did these would be listened to and acted upon.

The provider supported learning and innovation and promoted an open, learning culture. Leaders demonstrated that they understood the challenges to quality and sustainability.

There were appropriate arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care and treatment provided.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders ensured there was a shared vision, strategy and culture that staff in all areas knew, understood and supported. Leaders demonstrated an exceptionally positive, compassionate and listening culture and equality and diversity were actively promoted.

The culture of the service was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively.

Staff spoke of a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. All staff without exception felt positive about working at the practice. They described good teamwork and a service that was clear on its function to work in the interests of patients and providing the best patient experience they could. Regular meetings were held for clinical and non-clinical staff. Members of the team told us that communication was effective, and they felt included in decisions about the service.

Leaders were visible and inclusive, and they understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and staff embodied the culture and values of the organisation.

The leadership team worked with other practices in the primary care network (PCN) and were engaged in the development of primary care services within the local area.

Members of the staff team in a range of roles told us that communication across the service was effective.

The provider monitored and acted upon data about outcomes for patients. They made improvements when required.

Feedback from people who used the service was very positive with regards to the capability and compassion of the staff and leadership team.

The provider fostered a positive culture where people felt they could speak up without fear of detriment and their voice would be heard and concerns acted upon.

Leaders encouraged staff to raise concerns and promoted the value of doing so. We received a high number of completed CQC staff feedback forms and all staff who completed these felt well supported and confident to raise concerns.

The practice had established freedom to speak up arrangements. There was a dedicated ‘freedom to speak up’ person that staff could approach. There was also a whistleblowing policy.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Reasonable adjustments were made to support staff to carry out their roles. Staff with caring responsibilities were actively supported with a flexible approach and changes to schedules to accommodate their needs.

Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. The practice had an equality, diversity, and inclusion policy.

There were clear and effective arrangements for governance, management and accountability.

The provider used data to monitor and improve performance.

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 that were appropriate for the service. A regular suite of searches of the clinal record system were being run to identify patient needs and ensure these were being met.

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 used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data, records, and data management systems and staff took patient confidentiality and information security seriously.

Systems and protocols were in place to ensure data and notifications were submitted to external organisations as required.

There were arrangements for identifying, managing, and mitigating risks. A major incident plan was in place.

The provider worked collaboratively and in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop effective services.

The practice had a Patient Participation Group (PPG) and they engaged with the PPG on a regular basis. We met with a representative of the PPG and they told us the provider consulted with them and sought their views on the service provided and developments.

There was a focus on continuous learning and improvement across the service. For example, the service was a GP training practice.

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.

There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence.

The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality.

Leaders told us they maintained strong external relationships that supported improvement and innovation.