Church 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

We rated this key question as Good.

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 practice had a clear mission statement: ‘Care. Integrity. Commitment. Sustainability.’

We saw the practice took their mission statement seriously and were proactive in trying to meet these aims. For example, in line with the aim of being a ‘Caring’ practice, we were provided with multiple examples of where staff had demonstrated additional effort to care for the most vulnerable members of society including the homeless and people addicted to drugs.

The culture of the practice was open, transparent, blame free and non-discriminatory. We saw staff worked well together and the practice was well organised.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They endeavoured to be both present and approachable for staff.

Leaders actively engaged with patients, staff, and partner organisations to gather feedback and they took meaningful action in response. Leaders told us they operated an ‘open door’ policy and encouraged staff to raise concerns. They demonstrated during the assessment how they made changes for the better wherever they could. For example, in response to feedback from staff, the practice arranged additional training on the Accurx text messaging service for staff who reported experiencing difficulties. Leaders told us all staff were now confident in using the service following the training. In addition, leaders told us in response to staff feedback they had changed the administrative office location and relocated the prescription team to allow for a bigger telephone call centre and triage room.

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 practice strived to ensure staff could speak up and their voice would be heard. There were systems and policies in place to support staff to whistle blow or to speak with a ‘Freedom to Speak Up Guardian’ if they needed to. The practice had appointed a Freedom to Speak Up Guardian who worked externally to the practice. Wyre Forest Health Partnership had also arranged a staff council with staff representatives from each practice. Members of the staff council also acted a Freedom to Speak Up Champions.

The practice valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. Staff had received training in equality, diversity and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion and disability. There was a zero tolerance to bullying and harassment and leaders were committed to providing an inclusive and supportive working environment.

All staff reported high levels of job satisfaction and were encouraged by leaders to be involved in contributing to the running of the practice and improving the service delivered for patients. The Wyre Forest Health Partnership also welcomed suggestions from staff and had arranged for vouchers to be given for staff for their input.

The practice 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. Nominated GPs had been given lead clinical roles within the practice such as drug and alcohol addictions; LGBTQ+; women’s health; and diabetes.

The practice had established, embedded, governance processes and staff could access all required policies and procedures. Managers held regular meetings with staff, during which they discussed clinical and non-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.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for patients. They shared information and learning with partners and collaborated for improvement. The practice worked with other practices within their primary care network (PCN) as well as within the Wyre Forest Health Partnership, and attended meetings where practices shared best practice and quality improvement.

Staff told us they referred patients to the Pharmacy First service where appropriate. Pharmacy First is a consultation service which enables patients to be referred into community pharmacy for a minor illness or an urgent repeat medicine supply. The service helps to free up GP appointments for patients who need them most and includes the supply of appropriate medicines for 7 common conditions including earache, sore throat, and urinary tract infections, aiming to address health issues before they get worse.

The practice collected patient feedback regularly via the NHS “Friends and Family Test” and reported on these outcomes each month. On an annual basis, the practice reviewed the National GP Patient Survey results and identified areas for improvement.

In addition, the practice had a patient participation group (PPG) and staff had discussions with and collated feedback from the PPG to identify improvements for the practice. Staff told us they were working to increase the PPG membership and diversity; and had arranged a meeting for patients to tell them about the PPG and what the membership involves.

The practice had a strong focus on continuous learning, innovation and improvement. Staff participated in quality improvement work and used learning from significant events and complaints to continually improve the service they provided.

Church Street Surgery is a teaching practice providing training for medical students, Nurses, GP Registrars and foundation Pharmacists. The practice also offers work experience for local school pupils.

The Wyre Forest Health Partnership had a research team, and recent studies which the practices had been participating included ‘DaRE2Think,’ a University of Birmingham study, investigating whether earlier intervention with NHS treatments can prevent blood clots and memory loss in patients with atrial fibrillation, a common heart rhythm condition associated with vascular dementia; and the ‘ELSA’ NHS study for screening Type 1 Diabetes in children and young people.

Staff were enthusiastic about the Wyre Forest Health Partnership ‘CQC Dashboard’ which had been developed which collated data from all of the practices within the partnership and facilitated performance monitoring, sharing of information, and learning for improvement. In addition, the Wyre Forest Health Partnership had a business development committee. This committee meeting was designed to provide a structured forum where innovation was actively encouraged, reviewed, and embedded into practice.