Hagley 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 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.’ Staff explained they put patients at the forefront of everything they do. Staff told us by working collaboratively as a team and continually developing their skills, they aim to deliver care that is both safe and high in quality.

All the staff members we spoke with were positive about the culture of the practice. Staff told us it was a friendly environment to work in, the culture was open, transparent, blame free and non-discriminatory and they enjoyed working there. In addition to speaking with staff, CQC received written feedback from 17 staff members. All staff were positive about the culture of the organisation. Staff reported a good team spirit amongst colleagues and felt the practice was well organised.

Leaders had the skills, knowledge, experience and credibility to lead effectively. The practice Site Manager and the Deputy Site Manager had been supported to complete a leadership development programme to develop their knowledge and skills in leadership and management.

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.

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 of the staff we spoke with reported high levels of job satisfaction. They told us they felt valued and were encouraged to be involved in contributing to the running of the practice.

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 women’s health; diabetes; and Musculoskeletal (MSK) conditions.

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.

For patients living at a care home, the practice worked together with the care home staff in arranging care and the practice GP Care Home lead had weekly catch ups with care home staff. We saw evidence of meeting minutes between the care home and the practice.

Leaders told us that staff 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 oran 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 the reception appointment check-in screen had been lowered in response to patient feedback. Leaders told us they were also exploring ways to increase the membership to the PPG and had shared information about the PPG with patients via social media.

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. Leaders told us they encouraged staff to undertake further training and progress in their roles. For example, administrative staff had been provided with additional training for understanding patients with poor mental health; and one staff member who had been employed as a receptionist had been supported to train to become a Health Care Assistant.

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.

Leaders were proud of their working relationships with external healthcare professionals including District Nurses, palliative care teams, and safeguarding leads and felt their operated effectively as an integrated health care team.

The practice was keen to encourage people to develop careers in medicine and as such the practice taught medical students and arranged work experience for pupils.