Willington 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 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 good. At this assessment, the rating remains the same.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The mission statement was displayed around the practice. Feedback we received from staff regarding the culture within the practice was very positive. They told us it was a positive and friendly environment to work in, the culture was open, transparent, blame free and non-discriminatory and they enjoyed working there.

The service had 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 workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The service had a stable and experienced leadership team. Staff spoke positively about the leaders, that they were approachable and responded to any concerns raised. We saw 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.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. There were systems in place to support staff to whistle blow or to speak with a Freedom to Speak Up Guardian if they had any concerns. The practice had established Freedom to Speak up arrangements with another practice in the primary care network and with the local medical council. However, not all staff were aware of who these people were. However, staff felt they could speak up internally and were confident their voice would be heard and acted upon.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures although 2 required updating to ensure the information was up to date and accurate. Following our assessment, the provider sent us the updated policies. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. There were systems in place to ensure staff were kept informed if they were unable to attend meetings. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. Staff were encouraged and supported to attend local forums which provided networking opportunities with other services within the primary care networks. These included monthly practice manager and practice nurse forums. The practice manager also attended meetings organised by the local medical committee.

The service had an active patient participation group (PPG) which was supportive of the practice in driving improvements. The PPG acted as a conduit for communication between the local community and the practice. The PPG worked with the service to engage with young families who brought their children in with a view of asking them what they thought of the facilities at the surgery to encourage them to see the service as more inclusive. As a result of this engagement distraction toys for the walls in the breastfeeding room had been purchased to keep other children engaged during feeding. In additional, the baby change room had been reconfigured, the pull switch repositioned, the bins moved closer to the fold down platform and a shelf installed to make the room more accessible. New toys were also purchased via fundraising for the play area.

The PPG shared the details of the community health champion project which aimed to highlight success stories where people had followed their healthcare team’s advice and seen significant positive outcome. The objective of the project was to inspire other people to make lifestyle changes leading to long-term health benefits.

The practice worked in partnership with key organisations and agencies to support the provision of care and joined up working. Regular community support team meeting were held to share information about people in need of additional support.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The service was a well-established training practice for GP trainees. Systems were in place to support trainees during their placements. The service used learning from significant events and complaints to continually improve the service they provided.

Staff participated in quality improvement work.