South Hylton Surgery Also known as Sunderland GP Alliance Limited

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 looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture At our last assessment, we rated this key question as outstanding. At this assessment, the rating has remained the same, as outstanding.

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.

The service had a very clear shared vision, strategy and culture. This was based on candour, respect, innovation, safety, being a pro-active service, and remaining patient focused. Staff had contributed to the development of the practice vision and strategy, which was kept under review. Staff told us they were invited to regular meetings in which they could make suggestions and give feedback to the practice leadership. Staff told us that their suggestions were listened to and acted upon. Staff described a positive culture within the practice and were able to provide examples of teamworking and collaboration with the leadership. Leaders had a clear vision for the practice and were able to demonstrate improvements that had been made since our last inspection, such as the implementation of the online access system. Leaders monitored the progress of the delivery of their strategy by conducting reviews and audits of processes. We saw evidence that these had been carried out, and that staff had been involved in these reviews. Practice leaders were keen to involve staff in any changes. Most recently, 2 teams within the practice had merged following staff feedback. Prior to the change being made, leaders had arranged for individual discussions to take place between staff and an external individual, to gather information in a non-biased way. The practice displayed their statement of purpose clearly on their website. We saw evidence of strategic planning in the form of meeting minutes and action plans developed by the practice. We saw evidence that these action plans had been implemented. Leaders also told us about future plans for the practice, and the work that had already been done in the planning of this strategy.

The service had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their organisation.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had a freedom to speak up guardian and staff were aware of who this was and how to contact them. Following our assessment, leaders have introduced an external freedom to speak up guardian in collaboration with another local practice. There was a whistleblowing policy in place. Our assessment raised no concerns in this area.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. We saw evidence of flexible working arrangements being made to provide equal opportunities to staff. We also saw fair and equitable treatment of staff, with all staff receiving an equal benefits package. Policies and procedures to promote diversity and equality were in place. Staff had completed equality, diversity and inclusion training.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this with others when appropriate. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. A governance subgroup was held regularly with senior leaders to review complaints, significant events, policies, and any areas for learning. Senior leaders also reviewed all subject access requests on a quarterly basis to ensure these had been responded to and actioned within the appropriate time frame. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. There was a business continuity policy in place in the case of an emergency. Leaders were able to provide an example of emergency preparedness, providing evidence of their actions earlier this year during a system outage. There were effective processes in place for staff recruitment, and we saw evidence that the appropriate checks had been carried out for new staff. Repeat checks had also been carried out for existing staff to ensure ongoing suitability for their roles. Staff had completed all mandatory training and practice leaders had good oversight of what had been completed. Leaders also held a central database of all clinical audits and improvement projects that were ongoing, so these could be monitored effectively and repeated in a timely manner.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. The provider worked with other practices within their organisation to offer winter vaccination programmes. Staff had ensured the coordination of their service with aligned care homes through weekly multidisciplinary team meetings. Since our last inspection, the practice had held a mental health and wellbeing drop-in session, for people to seek support on their own mental health or to make comments to the practice on what could be improved. A representative from the Patient Participation Group (PPG) told us that they had open lines of communication with practice leadership, and that their feedback was listened to and acted upon. The PPG recognised the good relationships the practice had with the community, including the local school. We were told that the PPG had in the past met with other PPGs aligned to different practices to share best practice, and this feedback was welcomed by practice leadership. Leaders told us that the practice engaged with the community, such as providing CPR training for local young children. Aligned care homes had positive feedback for the practice in this area. They described good relationships with the practice, and smooth processes in accessing care for residents. Leaders within the care homes provided examples of improvements that the practice had made because of their direct feedback.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and individual practice. They always encouraged creative ways of delivering equality of experience, outcomes and quality of life for people. The practice had an ongoing action plan in place to guide improvements following the NHS England GP patient survey results. We saw evidence of implemented actions because of this plan. Practice leaders were able to provide many examples of improvements that had been made as a direct result of feedback or incidents. For example, additional external training had been provided to all staff to support patients who identified as a gender other than that which they were assigned at birth. In addition, leaders were aware of challenges being faced by primary care services and were working to improve. For example, recognising the challenges with opioid prescribing and conducting an audit and review of all people prescribed certain medications, which included consultations with the patients themselves. Leaders were also able to give examples of improvements made as a result of staff feedback, such as the merging of 2 teams within the practice to eliminate the duplication of work across teams. Leaders told us that educational sessions were held for staff on a quarterly basis, with themed topics being discussed. Staff were encouraged to engage in professional development, in the form of prescribing qualifications, diplomas, and management training. Monthly meetings were held to review Quality Outcome Framework data. Since our last inspection, the practice had become a training practice, providing placement opportunities to medical students. Leaders had increased the number of GP hours within the practice since our last inspection. Leaders had engaged with other practices to discuss health innovation projects and had recently implemented a new system to complete recalls and reviews.