London 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

We assessed all the quality statements in the well-led key question. We found some improvements to leadership and governance processes. However, there were still issues identified regarding some of the aspects of the provider’s governance and the management of risk which had also been identified at the last inspection. Our rating for this key question remains requires improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received staff feedback from a variety of sources. This feedback demonstrated that staff felt well informed and communicated with by the leadership team.

There were processes to plan for the changing demands of the local population. For example, a new appointment system was implemented in September 2024.

Staff we spoke with informed us they felt included and informed by the leadership team. They said they received feedback from investigation outcomes where incidents or complaints occurred.

Training on equality and diversity was provided to staff. There were meetings to share information and ensure staff had the opportunity to share concerns with their line managers and colleagues.

Staff feedback indicated they were aware of the freedom to speak up process and who the named person was. Staff were aware of the significant event processes and how to raise concerns.

Staff were provided with the organisation’s freedom to speak up information via a policy. There was a means of escalating concerns via the process.

Staff informed us they had access to equality and diversity and human rights training. Staff did not report any concerns surrounding inequalities within the workplace or in the delivery of services.

There was training for staff in equality diversity and human rights and these requirements were also included in the provider’s policies.

Staff told us about the governance processes used to monitor the care provided, the quality of the service and also safety of the service. They informed us about processes to monitor long term conditions management, medicine reviews, infection control and medicine management including emergency medicines and equipment. Staff knew who was responsible for areas of governance and their appointed leads who oversaw medicines management, infection control and the maintenance of premises and equipment.

Some of the provider’s governance systems had improved with the recruitment of new GPs and other staff since the last CQC assessment. Governance processes however did not always ensure risks were identified, assessed and mitigated. However, we still found risks related to the monitoring of high risk prescribing , and despite improvements being made, the concerns with the monitoring of these still posed a risk to some patients where their prescribed medicines required regular monitoring. Prompt action was taken after the assessment to provide interventions where needed to the affected patients. We also identified that limited and insufficient information was provided to reception staff to ensure identification of high risk symptoms could be identified and acted on in good time as part of the new system of triage. The new automated triage system was not always monitored after its implementation to identify if any patients requiring urgent interventions were identified appropriately. The monitoring of training had improved since the previous inspection in 2022. However, the practice had not ensured that all staff had the required training in line with national standards. The practice had undertaken a medicines optimisation audits to monitor prescribing. However, there was limited clinical audit used to identify areas for quality improvement.'

Patients received information from the provider regarding improvements to services made as a result of patient feedback. This included changes to the appointment system and clinical triage.

Staff and leaders worked with the Integrated Care Board (ICB) help improve patient care. This included working with the ICB medicines optimisation team.

Local commissioners confirmed the practice worked with them collaboratively.

The practice had processes to manage people’s care in co-ordination with NHS 111, care homes, GP out of hours and other external services. There was engagement and two way communication with the practice’s Patient Participation Group.

The leadership team informed us they had been focussed on making the improvements identified at our previous inspections. The provider informed us they had recruited more staff, including GPs, a clinical pharmacist and a new practice manager to enhance the skill mix within the practice.

The recruitment of clinicians and a new manager had enhanced the mix of staff who were able to contribute to improving outcomes for patients. They had contributed new ideas such as the implementation of a triage system. However, the implementation of this new system was still being scoped and tested to further improve its effectiveness.