Drs Leung, Mallick, Sherrell & Hobbs

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

Well-led – this means 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 Inadequate. At this assessment, the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. During our assessment of this key question, we found senior leaders promoted a positive staff culture. Staff reported they felt supported in their roles and could raise concerns openly and transparently. There were clear and effective processes for managing risks, issues and performance. There was a demonstrated commitment to using data and information proactively to drive and support decision making.

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.

Staff told us there was a positive team culture within the practice and that they felt supported by GPs and senior leaders. They told us they were able to contribute to discussions about service improvements, incidents and complaints. All staff we spoke with were proud to work for the service and had a vision to deliver high quality patient care.

There were established and effective systems in place to promote a positive culture of learning, collective best practice and performance. There was a practice mission statement developed by staff during annual practice TARGET training sessions. TARGET is a scheme aimed at improving patient care by learning new skills, sharing best practice and incorporates quality improvement activities. The practice mission statement and values were available and accessible to staff. Positive learning culture was demonstrated through meeting minutes which showed that performance, incidents, patient feedback and complaints were routinely discussed.

Staff told us the practice leaders were inclusive, approachable and visible and described the culture of the service as open, inclusive and supportive. They had confidence in the senior leadership team and GP’s and would raise queries or concerns directly with them. Staff were encouraged and empowered to lead on projects that suited their own professional areas of interest. They spoke proudly about the work and felt that they had been given the opportunity to develop their own leadership skills.

There were established and effective processes and systems in place for leaders to share their vision, practical experience and support with colleagues. This was achieved formally through supervisions processes, management meetings and clinical discussions. This was also achieved informally through being accessible to clinical and non-clinical staff if they had queries and required support.

Staff told us they were confident to raise concerns either via their management or the Speak up guardian. They reported that they felt able to raise concerns with leaders without fear of retribution and they knew how to access the whistleblowing policy. We received staff feedback as part of the inspection process which highlighted there was an ‘open door’ policy and leaders welcomed feedback for service improvements.

There were established and effective processes in place for staff to speak up without fear of reprisals. Staff could raise concerns internally and externally to safeguard the safety of people. There were opportunities for staff to raise feedback about the service through the annual staff feedback survey. Actions had been taken in the last feedback survey and were raised at the annual TARGET training day. There was a zero-tolerance policy in relation to the abuse of staff with mechanisms in place to protect people and minimise the likelihood of reoccurrence.

Staff we spoke to told us they had not experienced discrimination or discriminatory behaviour whilst working at the practice. Staff said the practice partners arranged social engagements and told us the team supported each other. The staff team described themselves as a diverse group who worked together, others described the team like a second family. Staff reported they discussed their working hours with their line manager and/or practice manager if they needed greater flexibility in their role or needed to change due to personal circumstances.

There was evidence from policies that leaders took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. There was no evidence of discrimination built into any of the policies we reviewed. Staff had undertaken training modules in equality, diversity and human rights. A staff survey had been conducted which demonstrated the practice had collected, analysed and responded to staff feedback.

Staff told us there was clear governance systems in place overseen by the senior leadership team. There was stability within the staffing structure that provided staff with confidence and consistency in the delivery of care to people. Staff told us that leaders were receptive to feedback and wanted to improve services to people. Staff we spoke with were clear about their role, responsibilities, and how they interact with other staff. They told us they had access to policies and procedures to support them within their role and attended regular meetings where discussions about the practice, such as complaints and significant events were discussed. Leaders told us about the ways in which they monitored and mitigated risks, through risk registers, assessments and improvement planning.

There were established systems in place to support service decisions, risks and improvement planning. Risks were effectively identified, assessed and mitigated for business continuity; staff training and recruitment, managing the appointments systems and information governance. However, practice processes had not always effectively identified when some patients had not been appropriately reviewed or adhering to monitoring guidelines to ensure safe prescribing for those patients prescribing high-risk medicines. The practice had formed a clinical governance sub-committee to address service performance. This included, audit activity, risk management, health and safety and to ensure patient safety standards were being met. Policies were in place and accessible to staff. Staff used data to monitor and improve performance. For example, senior leaders regularly reviewed data of patient accident and emergency attendance figures; workflow of patient correspondence; appointment capacity, telephone key performance indicators, and quality outcomes framework (QOF) performance data. There was a Caldicott Guardian in place and robust arrangements for the availability, integrity and confidentiality of data. Patient data and information was stored securely in line with digital security standards with relevant information was made available for patients to access in line with privacy, consent notices and general data protection regulations. Workflows for communication and pathology results were up to date at the time of our assessment. Managers met with staff regularly to complete appraisals and performance reviews.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff and leaders told us they had strong relationships with healthcare professionals within the local community to support care provision and joined-up care. Staff spoke positively about the work that was happening in the local community, and were proud to have made an impact.

We spoke with the NHS Hampshire and Isle of Wight Integrated Care Board ahead of this assessment. From the feedback we received from them there was no indication of concern in this area. Feedback from community providers highlighted positive experience working with the practice, including a collaborated approach to monitoring and providing care and treatment for patient’s needs, such as those with protected characteristics; patients with poor mental health and for end of life care. Feedback from the Patient Participation Group (PPG) highlighted they were listened to, valued and had seen positive changes to improve patient experiences. For example, the practice had reviewed local care pathways including resources within the Primary Care Network (PCN). The PPG noted positive feedback in relation to the practice’s response to acting upon correspondence from secondary care providers and referrals demonstrating effective local care pathways.

There were systems and processes in place to gather feedback specific to service provision from partners in patient care such as the Primary Care Network (PCN), healthcare providers within primary, secondary and community care as well as feedback from service users and groups such as the Patient Participation Group (PPG).

Leaders demonstrated examples of quality improvement activity. For example, the practice implemented dedicated mental health review clinics, which provided a specialised service managing patients with mental health conditions. Its purpose was to assess patients' progress, treatment plan reviews, ensuring medication efficacy, and addressing any challenges or concerns in patient care. During the mental health review appointments, all outstanding safety alerts and monitoring processes, including quality outcomes framework (QOF) parameters were actioned, such as patient diabetic foot checks, blood tests, blood pressure checks, annual electrocardiograms (ECGs), adjustments to medication, outstanding vaccinations, anthropometrics (such as height and weight) were recorded and reviewed. As a learning point for future clinics, the practice considered clinical staff arrangements and ways to reduce did not attend (DNA) rates. Staff told us patients found these clinics provided positive outcomes for long-term management, and maintaining mental well-being. Leaders told us the practice had formed a clinical governance sub-committee to address service performance including, audit activity, risk management, health and safety and to ensure patient safety standards were being met. We saw evidence of an action plan in place following our on-site visit in July 2024 as part of the practice’s ongoing improvement planning. Staff told us there was a strong focus on continuous learning and improvement and documented learning outcomes following governance and practice meetings were shared with the wider team.

The practice incorporated the GP Improvement Programme (GPIP) in October 2024 as a strategic tool to review the existing access appointment model into a “Modern General Practice Access Model”. GPIP is a 20-session programme, run over 6 months, with an NHS England’s delivery partner. The practice was assigned an experienced Quality Improvement (QI) facilitator. GPIP looks at a variety of practice areas including access, capacity management, clinical and back-office functions and the processes around how a practice operates. As well as on-site practice visits, the support included interacting with other practices as part of a group learning approach to celebrate success and share tips and solutions. The practice piloted a program to transform patient experiences, improve outcomes, and enhance efficiency through ‘GP Automate’, removing the need for human input when processing and reviewing normal patient laboratory reports. Patients were sent their results, and their records were updated without the need for actioning by a GP. Following the trial, the practice planned to undergo further trials with a similar system, ‘MyBotGP’, to investigate some administrative patient correspondence filing programs. At the time of assessment, these trials were currently awaiting start dates. The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example, there was a clear plan for conducting clinical and non-clinical audits, with dedicated leads for audit areas. Outcomes and learning were shared with staff. The provider was listed as a training practice which supported and mentored GP registrars, advanced clinical practitioners and nursing associates. Healthcare assistants had development opportunities for trainee nursing associate roles. There were 2 GP trainers assigned as mentors, the practice worked with Southampton university regarding tutorial support for medical students.