Roysia 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

There were clear, comprehensive, effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. There were robust 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. Leaders implemented quality frameworks to improve equity in experience and outcomes for people using services and tackle known inequalities. Outcomes for patients were demonstrably improved due to comprehensive audit and shared learning processes, and led by a strong leadership structure.

This service scored 93 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were encouraged to attend monthly staff meetings during which updates, and new information was shared. Minutes of the meeting were recorded and accessible to all staff on the practice electronic system. Staff were aware of their own responsibility for completing required training and actions that would be taken by the practice if their training was not completed. Reminders were provided by the practice to all staff via the practice electronic system when training was due. There were regular staff meetings in which learning, for example following significant event investigations, and updates were shared. Staff made positive comments on working within the practice. All staff fed back they enjoyed going to work. Staff referenced cohesive teams who worked well together. The implementation of a duty GP, worked well for staff who fed back it helped to have a GP available and willing to answer queries and provide help during clinics as well as triaging patient requests. Staff told us there was a positive culture and we observed this during our assessment. Practice staff were observed and evidence was seen which identified an understanding of how the practice delivered care, treatment and support for people. The strategy, vision and values of the practice were known by every staff member. The practice had oversight and assurances obtained of the work carried out by non-medical prescribers. The provider listened to staff and took action in response to feedback, for example, replacing clinic room taps from elbow ones to sensor motion ones. Staff were able to give feedback, share thoughts or concerns with ease and this was positively promoted by the provider and practice manager. Staff said they felt like a family being able to talk openly and honestly.

There were a significant amount of positive comments regarding the support provided by team leaders, management of Roysia Surgery and the provider/owner Malling Health (UK) Limited. Staff said they were extremely well supported, listened too, any changes were discussed with them and they could recount scenarios from learning events which had been facilitated and supported by the senior team. There were clear and effective communication processes from the provider to the practice with actions taken that showed continued focus on learning and improvement for the whole service. This in turn had positive outcomes for those using the service which contributed to a positive staff and team culture.

All staff spoken with, were able to give the freedom to speak up policy detail, contacts at the practice, at provider level and also locally.

All staff had completed all of their training for equality and diversity and there was a practice policy staff were able to describe in detail. The practice employed a person with disability and they told us that they had felt supported by the measures placed to support their role, for example, larger PC screen and keyboard. The provider had also completed a bespoke fire risk assessment and disability risk assessment for this staff member.

Leaders were knowledgeable about issues, challenges and priorities at the service and had a shared vision/focus to strive to deliver the highest quality person-centred care. This included detailed understanding and oversight of risks and actions to mitigate and minimise them. For example, risks highlighted by consultation notes audits and SBAR tool, allowing swift intervention and proactively improving outcomes for patients. Staff worked collaboratively with other practices through their primary care network and local integrated care board. The approach to employee well-being linked to the positive staff culture with staff feeling valued and listened to. There were clear and effective governance, management, and accountability arrangements. Staff understood their role and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. There were robust arrangements for the availability, integrity, and confidentiality of data, records, and data management systems. Information was used effectively to monitor, learn and improve the quality of care. Quality frameworks were in place to improve equity in experience and outcomes for patients and tackle known inequalities. An audit program was in place to monitor performance and promote quality improvement. There was a suite of policies to support governance throughout the practice. A data security and protection toolkit policy set out the practice framework for maintaining and enhancing high-quality data such as complete, accurate, appropriate, accessible, and timely data in all forms.

Leaders were knowledgeable about issues, challenges and priorities that the service may face and had a shared focus to strive to deliver the highest quality person-centred care. For example, the leaders had a good understanding about risks and implemented actions to mitigate such risks, for example, the risks highlighted by the consultation notes audits and SBAR tool. The practice worked collaboratively with other practices through their primary care network and local integrated care board. Staff wellbeing was a strong focus which was evident through speaking with staff. There were clear and effective governance, management, and accountability arrangements. Staff understood their role and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. There were robust 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. Leaders implemented quality frameworks to improve equity in experience and outcomes for people using services and tackle known inequalities. There was a comprehensive overarching risk assessment system in place to monitor risks to the service. An audit program was in place to monitor performance and promote quality improvement. There was a suite of policies to support governance throughout the practice. A data security and protection toolkit policy set out the practice framework for maintaining and enhancing high-quality data such as complete, accurate, appropriate, accessible, and timely data in all forms.

We saw strong links between the local primary care network and the provider. There were consistently high levels of constructive engagement with staff and patients. The service had not received any formal complaints. We reviewed the online feedback the service had received from 59 patients. All feedback was very positive about the service with patients rating the service 5 out of 5 stars for feeling listened too and their feedback being taken into account and acted upon. Managers contacted people so they could give feedback in an honest and open way. This enabled people to raise concerns if they needed to. The service was transparent and collaborative with stakeholders. For example, the work to improve health inequalities and also the multi disciplinary joint services safeguarding meetings held 2 monthly. The service had a whistleblowing policy in place. A whistle blower is someone who can raise concerns about practice or staff within the organisation.

There was a provider monthly quality governance meeting at board level that reviewed significant event analysis learning, any complaints, patient experience, data review and data protection. There was a central computerised programme that could show data for this meeting and also had the functionality to share medicine updates, clinical guidance and evidenced based practice updates and this programme had an additional feature whereby leaders could track who had read and understood all shared information. The provider had received positive feedback from the local councillor on the work being completed for tackling health inequalities and leaders told us the practice was proud to be commencing a new children and young persons support project which would refer families to a support worker whilst awaiting a mental health diagnosis. Examples in our whole assessment, plus discussion with leaders demonstrated how they focussed and prioritised effectiveness of people’s care and treatment above all else. Leaders and staff spoke about the importance of assessing and reviewing patients health, care, wellbeing and communication needs with them and could demonstrate the actions they took in response, with measurable outcomes.

There was monthly formal auditing of prescribing practices that were led by the provider clinical lead and all learning was collated and shared with every staff member, regardless of grade. There was a strong and cohesive structure to governance that led staff to be able to recount learning events from both clinical and non clinical situations and what learning was and how change had been implemented. There would be regular meetings with the practice and then practice meetings to ensure all communicated changes and learning was effectively disseminated. Leaders had ensured all staff training was 100% compliant and the leadership team ensured all locum staff were treated in the same way as all employed staff and were given the same level of audit to ensure consistency of service delivery.