Caskgate 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 practice had a clear vision and strategy to provide high quality, person-centred care although improvements were required. The practice had a stable, core team of a lead GP partner and long-standing salaried GPs or locum doctors who had clear lead roles and responsibilities. There were ongoing discussions regarding a second GP partner being appointed. Since the inspection in 2023 under the previous provider leaders were open and transparent and had completed a series of actions to ensure concerns highlighted during that inspection were promptly addressed, such as management of long-term conditions, patient safety alerts, medication reviews, risk management and building maintenance, safeguarding, incoming correspondence and tasks and storing of patient records. They had an action plan which had been completed in 2023. There was compassionate, inclusive and effective leadership and the practice involved the public, staff and external partners to sustain high quality care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders were able to demonstrate that they had the capacity and skills to deliver high quality sustainable care and that they understood the challenges to quality and sustainability. Improvements that had been implemented now needed embedding. Staff reported there was an open and honest culture within the practice, were proud to work for the service and held a shared objective to deliver high quality patient care. There was an emphasis on the safety and well-being of staff.

Equality and diversity training was undertaken by all staff to better understand the needs of staff and the practice population. There were clear processes in place to manage any behaviour inconsistent with the practice vision and values.

Staff told us there was compassionate, inclusive and effective leadership at all levels. The leadership team had made effective changes to the culture of the practice which had been embedded and sustained. They were knowledgeable within their role and prioritised the quality of the service they delivered with appropriate support to all staff. Staff told us leaders listened to their feedback and shared some examples where changes had been made. The practice had also introduced an employee of the month scheme to recognise and celebrate staff achievement and contribution. Staff told us they received regular appraisals and were given opportunities to discuss development and any training needs during their appraisal. They told us management had an ‘open door’ policy and they could approach leaders at any time if they required support.

At this assessment we found the practice had improved the meetings structure with regular meetings scheduled for different staff groups and set agendas in place. Full practice meetings had been introduced and taken place but to date had been used for training and updating about new systems introduced in the practice. The practice manager told us that going forward these would be more structured and follow the set agenda.

Staff reported there was an open and honest culture within the practice, and they felt able to raise concerns with the management team and leaders. The practice had access to a Freedom to Speak Up Guardian. However, some staff told us they were not aware of who this was. The practice manager told us they would remind staff of the process and ensure all staff were aware of who the Guardian was, should they wish to raise any concerns.

The practice had a raising concerns (whistleblowing) policy and there were systems to ensure compliance with the requirements of duty of candour.

Leader ensured all staff could be heard through various routes of communication such as, suggestion box, staff survey, appraisals, meetings and being approachable at all times through an open-door policy. Staff felt empowered and were confident that their concerns and ideas resulted in positive change to shape services and created a more equitable and inclusive organisation.

Staff had completed equality and diversity training.

Leaders and managers supported staff and there were clear responsibilities, roles and systems of accountability in place. Staff told us they had access to practice policies and procedures, which were reviewed on a regular basis.

Governance systems and oversight had been improved by the introduction of a new knowledge, compliance, and workforce management platform. However, the shortfalls in oversight of some systems and processes resulted in patients being exposed to risk. We found gaps in some systems and processes including the management of some patients with long term conditions or monitoring of some patients prescribed high risk medicines, management of emergency equipment and medicines, monitoring of the efficacy of vaccines, staff recruitment files and the detail in some patient records. The practice were responsive to our findings and assured us required actions would be completed as a priority. The practice did not have an effective system in place for monitoring the quality of care provided due to the lack of continuous audit cycles to identify early identification of issues. At this assessment we found that the practice now had an effective system and process in place for oversight, management and responding to national patient medicine and safety alerts. Designated staff members managed the process to determine which alerts required action and to ensure that the actions were completed and information shared with relevant staff.

We did not receive any feedback from people who used the service relating to partnerships and communities.

We found staff and leaders were open and transparent, and collaborated with all relevant external stakeholders and agencies. Leaders attended regular primary care network meetings to discuss ways they could implement more coordinated and integrated health and social care for people closer to home. The management and leadership team met regularly to discuss challenges within the practice and ways in which they can improve the quality of care to better serve the practice population and improve relationships with external agencies.

Staff and leaders engaged with people, communities and partners to share learning with each other that results in continuous improvements to the service. They used these networks to identify new or innovative ideas that can lead to better outcomes for people.

The practice had recently changed its patient clinical record system which had enabled them to be aligned with health care professionals on a single clinical IT system for healthcare.

Staff told us about learning opportunities they had been given to further develop their skill set and branch into other roles. Leaders demonstrated a positive learning culture which was inclusive to all staff which improved the working environment and care provided to patients.

Staff were supported to prioritise time to develop their skills around improvement and innovation. There was a strategy in place to develop these capabilities and staff were encouraged to contribute to improvement initiatives. Protected time was available to staff to complete training or projects, the practice leaders were enthusiastic regarding the development of their workforce. We found there was informal clinical supervision available but a lack of formal documented clinical supervision.