Village Medical Centre

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 Requires Improvement. At this assessment, the rating has changed to Good.

At our last assessment, the service was in breach of regulation in relation to:

• The provider was unable to demonstrate that there were effective governance processes in place to ensure risks were regularly reviewed and monitored.
• The provider was unable to demonstrate how they were acting on patient feedback.

At this assessment we found breaches previously identified had been acted on and improvements had been made to ensure governance processes had been strengthened to mitigate risks.

The practice had designated roles for areas of accountability. There were succession plans in place, supported by a business plan and the practice regularly reviewed the plans to ensure quality outcomes were fully sustained.

Leaders and staff shared a clear vision and culture in listening, learning, and mutual trust. Staff told us the leadership team were supportive, actively fostering staff development. Staff reported feeling empowered to provide feedback and described a workplace culture that promoted equality and was free from bullying or harassment.

This service scored 75 (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.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care. Team members highlighted effective communication and stated that they felt included in decision making processes relating to the service.

The practice had a realistic strategy and supporting business plans to achieve sustainability. Part of the business plan was to extend the premises with an increase in consultation rooms and a triage suite. The leadership team were committed to working collaboratively with their primary care network (PCN) and the local community to educate and achieve positive outcomes for their patient population

There were systems to ensure compliance with the requirements of the duty of candour and processes were in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity.

Staff had access to clinical supervision, learning and development events as well as educational support and all staff had access to online learning systems. The leadership team provided regular reflective practice sessions and enabled flexible working where able. The practice was a training practice for GP registrars and had also supported the training and development of pharmacists.

There was an open culture and clear learning within the practice. Regular meetings were held with staff, and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

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.

Staff told us that their wellbeing was considered, and their views respected, and concerns acted upon. These included, for example, reasonable adjustments to support staff to carry out their role.

Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the PCN 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.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were policies and procedures in place for the safe recruitment of staff. Other policies included recruitment, equality and diversity, bullying and harassment and grievances.

All staff had access to regular appraisals, one to ones, coaching and mentoring and revalidation. There was an induction process in place for newly appointed staff and staff told us that they were well supported and felt able to ask for advice. Staff told us they were encouraged to develop within their roles and training opportunities were available. Information provided by the practice showed 2 of the nursing staff had been supported by the leadership team to complete prescribing courses.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

We found improvements since the last assessment with effective processes in place to demonstrate that there was clear oversight of governance arrangements to ensure risks to patients were considered, managed and mitigated appropriately. The areas we identified during our remote clinical searches were promptly actioned by the leadership team.

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. Staff could access all required policies and procedures.

Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

Staff took patient confidentiality and information security seriously. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures.

The practice carried out regular audits to monitor service provision and improve the quality of services provided. For example, medicine related audits, access, complaints, significant events and patient feedback.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders told us they worked with stakeholders and the local community. The practice was part of a primary care network (PCN) which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development.

The practice offered extended access, flu and covid vaccination programmes. Staff had made adjustments and collaborated with local services to further support community healthcare services. For example, providing support to care homes, with regular ward rounds and direct emergency telephone access to provide care and support to those at higher risk of hospital admission.

The practice was collaborating with a local pharmacy to deliver designated referral pathways to the Pharmacy First scheme. Liaison officers were in place to discuss medicine related queries and quarterly meetings were held to share information.

A patient participation group (PPG) was in place; and meetings were held on average every 3 months. We spoke with a member of the PPG who told us there were not many in the group currently, however the leadership team told us they were actively trying to encourage patients to join. The practice had engaged with the PPG on areas of improvement such as complaints, access and local services available.

The leadership team were aware there had been increases in demand and they were working with the PCN and stakeholders to ensure that resources were planned with continued collaboration and partnership working to meet the needs of the service.

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. They actively contribute to safe, effective practice and research.

The leadership team held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided.

The practice had a quality improvement plan in place to help drive service delivery. This included regular monitoring of the appointment system. The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.

The clinical team had been involved in a range of clinical improvement projects. For example, to reduce the risk of cardiovascular disease, working closely with a pharmaceutical company.

The practice was a training practice for newly qualified doctors. At the time of the assessment there were 2 registrars working at the practice. The practice provided direction and support to all trainees including daily reviews and discussions to monitor their progress. The clinical leadership team had also provided mentoring to pharmacists within the locality to support them in achieving their independent prescribing qualification. At the time of the assessment there were 2 pharmacists being provided with support and guidance by the GP team.