Church Walk 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 care; supported learning and innovation; and promoted an open, fair culture.

We found a positive culture which was open and fair, innovation and learning was encouraged and supported. Leaders and staff had a shared vision supporting safe care. Leaders were visible and supportive. The service had clear responsibilities, roles, systems of accountability but systems and processes in place to support good governance were not always effective, formalised or in place.

The provider was responsive to our findings and took immediate action to manage any risk and provided an action plan to indicate future planned changes. We have not assed the effects or sustainability of the planned.

This is the first assessment of the service and we rated this key question as requires improvement.

The service was in breach of legal regulation relating to safe care and treatment and 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 service had a shared vision, philosophy and set of values, which was shared with all staff are part of their induction, displayed around the building and on the practice website. The service aimed to provide high quality, safe and compassionate care in partnership with their patients, to seek to continuously improve the service offered and offer an excellent training environment. Staff and external stakeholders were very positive about culture within the practice and described it as open and transparent.

Staff and leaders demonstrate a positive, compassionate, listening environment that promotes trust and understanding between them and people using the service. There is mutual trust and respect between leadership and staff.

Both the provider and staff are aware of the risks to delivering the strategy and have an action plan to address them. For example, the major risk to the strategy is identified as the restraints due to the building size, to increase and improve service. The provider has been and remains in discussion with the local ICB and building’s owner on how to address this.

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

The service had a stable leadership team; they have been in place since 2022 when the practice reregistered. 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 to gain experience and were engaged in the development of primary care services within the local area.

Staff and leaders acted with openness, honesty, and transparency. Staff we spoke with confirmed this was a consistent approach across the whole practice.

Staff and leaders actively promote staff empowerment to drive improvement. They encourage staff to raise concerns and promote the value of doing so. All staff told us they were confident that their voices will be heard.

There is a culture of speaking up where staff actively raise concerns and those who do (including external whistleblowers) are supported, without fear of detriment.

When concerns are raised, leaders investigate sensitively and confidentially, and lessons are shared and acted on.

When something goes wrong, people receive a sincere and timely apology and are told about any actions being taken to prevent the same happening again. We saw evidence if this in the complaint responses and reviewed meeting minutes.

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. Staff told us they felt supported, were treated equally, and were free from bullying and harassment.

Policies and procedures to promote diversity and equality were in place. We saw that staff had completed mandatory training on equality and diversity.

The service had identified clear responsibilities, roles and systems of accountability following the changes to the partnership. The changes required following the formation of the new partnership were extensive and many improvements had been made

The provider did not have oversight of some of the issues we found during our assessment this led to ineffective governance in some areas. The systems and processes in place were not always effective and some were not in place.

This meant that performance, outcomes and risks were not clearly understood, monitored, managed consistently or effectively by the provider.

For example, process regarding review of tests results did not always ensure a timely review was undertaken, monitoring of staff training was not effective, long term condition reviews, medicines monitoring and medicine reviews were not completed according to guidance and MHRA safety alerts were not acted upon consistently.

The provider made some immediate changes during our assessment and devised and commenced an action plan to address the issues. The sustainability and the impact of these changes could not yet be assessed.

Leaders and managers supported staff and all staff we spoke with were clear on their individual roles and responsibilities. Processes were in place for appraisals. Staff knew how to access all required policies and procedures. Regular meetings were held with staff, during which clinical concerns and emerging risks were discussed. 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 partners at the practice had repeatedly sought different solutions to the access problems due to the constraints of the building. They recognise the significance of this in regard to breaching the legislation set out in the “Equality Act 2010” and the ever increasing patient population. Despite long standing discussions with the ICB, we saw evidence this was raised by email in 2020 no solution was in place at the time of our report. The management of patients currently affected by this had been provided with individualised care by the managers.

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 collaborate for improvement. The provider worked with other practices within their PCN to offer enhanced access appointments. Staff were encouraged and supported to attend local forums which provided networking opportunities with other services within the PCN and ICB. These included safeguarding meetings and immunisation forums.

The practice had an active PPG and Friends of Church Walk Surgery Volunteer Group. Both groups were consistently supported by the leaders from the practice who attended meetings and undertook or assisted with the administration.

There were processes in place to work in partnership with key organisations and agencies to support the provision of care and joined up working. For example, district nurses, community matrons, specialist nurse and the home care team. Feedback from representatives of the care home where the service provided care and treatment was positive about the practice.

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 provider acted immediately to the concerns we identified to mitigate risks and provided information following our assessment on plans to improve the service. The implementation of the plans and any effect has not been measured.

The service used learning from significant events and complaints to continually improve the service they provided. The service had monitored and completed audits to measure the impact of transitioning to a new appointment and telephone to identify and respond to any concerns