Hightown Village 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. This is the first assessment for this service since its registration with CQC. This key question has been rated as good.

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. The practice promoted a positive and compassionate culture that supported trust and understanding between staff and patients using the service. Learning and development were supported.

The provider understood the challenges and needs of people and their communities and was collaborating with partner agencies to support people effectively. Feedback from staff described the culture of the service being positive and teamwork being good.

Leaders had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty. 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 demonstrated the importance of staff wellbeing to support them in maintaining good outcomes for patients. Staff told us managers and partners were visible. The provider was knowledgeable about issues and priorities for the quality of services and staff told us there was a compassionate management team.

Leaders encouraged staff to raise concerns and promoted the value of doing so. The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Staff who provided feedback through our staff questionnaire or during our onsite assessment felt supported and confident to raise concerns. Staff had clear safe routes to raise concerns, there was a whistleblowing policy and staff had been provided with access to an independent freedom to speak up guardian to better promote transparency, trust and psychological safety within the workplace.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by supporting equality and diversity for people who worked for them. Staff felt empowered and confident to raise concerns and ideas. Reasonable adjustments were made to support staff to conduct their roles. Staff with caring responsibilities were supported with a flexible approach and changes to schedules to accommodate their needs. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff. The practice had an equality, diversity, and inclusion policy.

There were arrangements for identifying, managing, and mitigating risks. The service had clear responsibilities, roles and systems of accountability and used these to manage and deliver good quality, sustainable care, treatment and support. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Patient confidentiality and information security were well understood and consistently upheld.

Staff we spoke with were clear on their individual roles and responsibilities and they could access policies and procedures. Opportunities for learning and development were identified during annual appraisals and appropriate training was provided.

The practice demonstrated a commitment to work within their community. The provider worked collaboratively and in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop services. The practice did not have an active (PPG). A designated member of staff took the lead for patient engagement, and they told us of the events and actions they had taken and were planning in order to encourage patient participation, including attempts to encourage uptake of a (PPG). Staff told us they were working in partnership with Healthwatch to establish and support (PPG) development for the practice. Leaders had attended Parish Council meetings in the past and expressed a commitment to engage with future meetings when invited. Some partners reported that access to the practice had been challenging and that the service had not always been as responsive as they would have liked in meeting individuals’ needs.

Leaders and staff were proactive in sharing ideas and using good practice to improve care. They regularly listened to feedback from patients and the community, using it to shape and assess new ways of working. Examples included the digital front door which was implemented in part due to feedback from patients about their experience of booking appointments and the practice newsletter which is published on the practice website.

The service worked within a multi-disciplinary team to provide the right support for patients. The service actively participated in regular meetings where people’s care and treatment needs were discussed to improve their outcomes. There was a focus on continuous learning and improvement within the service.