High 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 looked for evidence that practice 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 inadequate. At this assessment, the rating is requires improvement. The practice has a regulatory history of requires improvement and inadequate ratings since April 2015. Over this time, practice leaders had acted when breaches of regulation were identified and at this assessment, we found improvements had been sustained through changes of leadership. However, improvements were still needed to the provider’s governance and monitoring systems to ensure all people had a timely medicines review, the consistent use of coding, and the management of actions from correspondence. We also found there was not an effective system to ensure prescription stationery was kept securely and monitored. The provider’s governance systems did not always identify, effectively monitor, and address areas for improvement we found during this assessment. The provider remained in breach of legal regulation in relation to good governance.

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.

The practice had a shared vision, mission statement and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding the needs of people and their communities and the potential future challenges to the practice.

Practice leaders worked to manage and address the future needs of people and their communities. For example, in 2024, practice leaders had increased their consulting rooms to 12 by moving clinical paper records off site. The practice had been approved as a training practice in July 2024. The practice had a business development plan from January 2025 to January 2028 which detailed a range of ways the practice planned to further develop, which included further developing their succession plan. The practice worked with partner agencies to address current and future challenges.

Most staff were positive about the culture of the practice and told us they felt valued and supported by practice leaders.

The practice had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Most leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with openness and honesty.

Practice leaders had strengthened their partnership with the addition of 2 GP partners, who were in the process of being added to their CQC registration. They were taking a more active role in the future leadership of the practice. The practice had also appointed a new Practice Manager. Leaders had accessed appropriate support and development in their roles. The leadership team worked with other practices in the Primary Care Network and were engaged in the development of primary care services within the local area.

Practice leaders encouraged teamwork and supported this through staff events which included for example nights out, and a Christmas quiz. Staff were valued and all staff received a Christmas and Easter gift. A staff information board included the National GP Patient survey results and information, contact details for sources of support, voting for preferred social events and details about compliments received.

Practice leaders had undertaken staff surveys in December 2022/January 2023, June 2023 and April 2024. Staff responses to most questions had improved over this time, which included for example, the visibility and support from managers and GPs, communication and motivation. Areas for improvement were identified for example, knowledge of those with lead roles. The majority of staff we spoke with were aware of those with lead roles in the practice.

The practice fostered a positive culture where staff felt they could speak up and their voice would be heard.

All staff we received feedback from were aware of the Freedom to Speak Up arrangements in place. The majority of staff told us leaders in the practice were approachable and responded to any issues or suggestions for improvement. For example, longer appointment times were agreed for clinical staff working in extended roles, as they often sought advice from the duty GP during consultations.

There were clear processes in place for staff to speak up and the practice had an internal and external Freedom to Speak Up Guardian. All staff had completed freedom to speak up training.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Practice leaders encouraged teamwork and inclusivity and supported this through staff events.

Staff gave examples of support they or other staff had been given for example, with flexible working, arrangements for time for religious beliefs to be practised and reasonable adjustments being made. Staff also gave examples of practice fundraising events, which helped to promote inclusion, where donations had been given to local charities.

Policies and procedures to promote diversity and equality were in place. Risk assessments had been completed for staff to ensure they were able to undertake their work safely and included the completion of occupational health recommendations. We saw adjustments had been made to ensure all staff were valued, for example adjustments to support disabled staff were in place. All staff had completed equality and diversity training.

The provider could not evidence effective governance systems which were sustained over time. Their systems did not always identify, effectively monitor, and meet all areas for improvement identified during this assessment.

Following the previous inspection the practice had made some improvements. However, their previous action plan to improve medicine reviews and coding had not been fully met. They still could not evidence that all people had a structured and comprehensive medicines review. We identified reviews which continued to be coded on the clinical system with no evidence in the record that all medicines were considered. This had not been identified or escalated by their assurance systems. Our clinical searches found there was still not an effective system for coding, and coding was not always used consistently. Processes in place to act on correspondence received by the practice, were still not always effective. A practice audit in December 2024, found hospital discharge summaries were not always actioned or completed in a timely manner. The practice did not evidence that all people prescribed gabapentinoids had received a medication review in the previous 12 months.

We found some policies and procedures were not in place or sufficiently detailed to ensure safety and safe systems of care. This included the management of coding and prescription stationery. There was not an effective system for the secure management and control of prescription stationery. The practice could not account for all prescription stationery and confirmed this had been reported externally. This had not been identified by the provider’s governance arrangements. Following the site visit, the provider submitted some assurance, however we were not fully assured their new process would ensure the security of all prescription stationery. In response to these concerns, leaders advised they would review their clinical leadership roles, capacity, policies and governance processes.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We received no specific feedback from people regarding their experiences for this quality statement. The practice had an active Patient Participation Group (PPG) who represented the views of people using the practice. The PPG and practice staff met face to face every 6 weeks to offer support, feedback and develop and review the practice. Meeting minutes were shared with approximately 50 people who were on the PPG distribution list. There was two-way feedback and learning which resulted in improvement to the practice.

Following their previous inspections in October 2022 and January 2023, the GP Partners had worked with the Integrated Care Board (ICB), developed an improvement action plan and met regularly to support and monitor progress. In August 2023, these meetings were no longer deemed necessary. Feedback from partners was positive regarding the changes made at the practice.

The provider worked with other practices within their Primary Care Network (PCN) to offer, Saturday and some evening appointments, NHS health checks and cervical screening. For example, the PCN health and wellbeing coaches organised a one stop health and wellbeing event in January 2024 at Lowestoft library, with 28 outside agencies attending to support. Practice staff engaged with external agencies to support people living in the community. For example, Suffolk Centres for Warmth were available at the practice during a Covid-19 and flu vaccination clinic.

The practice focused on continuous learning, innovation and improvement across the organisation and local system.

There was a learning culture in the practice which leaders actively encouraged, and all staff participated in. Most staff gave positive feedback about their experiences of joining and working at the practice, and the ongoing support and development they received. Practice leaders told us that leaders encouraged development, for example, a practice nurse had completed cervical cytology training, and a nursing associate had qualified as a registered nurse, both were supported by the practice. Training events were held at the practice, which included for example ‘lunch and learn’ sessions which had recently covered diabetes, coding and spirometry. We saw examples of shared learning with other services.

The practice had been approved as a training practice in July 2024. The practice had 1 GP trainer and was a training practice for medical students and GP Registrars (qualified doctors training to become GPs). The practice also supported placements for training paramedics. There was a process for GPs to peer review each other’s consultations for assurance and learning.