Wellspring 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 meant the service was managed and well-led. Leaders were very compassionate and inclusive, and staff felt supported and valued. The culture they created promoted high-quality, person-centred care.

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.

There was a clear mission statement, which was displayed within the practice. The service’s vision showed aspirations to provide the highest possible standard of professional interaction with people, staff and wider community. The service committed to provide high quality and accessible healthcare and to treat people with courtesy and respect and strive to develop the practice to be a leader within the community.

The service had a shared vision and culture to provide proactive and preventative medicine and keep people healthier and out of hospital for longer.

Practice leaders told us they held planning meetings with managers from Modality Partnership, the provider organisation, to agree a practice development plan, succession planning and review staffing levels to promote sustainability.

Staff were positive about the culture within the service and described it as open, transparent and supportive.

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 always did so with integrity, openness and honesty. The service had an experienced and strong leadership team. There had been significant changes in the partnership and management in recent years due to retirement of long serving staff and latterly the new partnership with Modality Partnership. The population which they served had recently grown from seven thousand people to ten thousand people, after two neighbouring practices had closed. The remaining partners adapted to the changes and worked hard to ensure stability of the service whilst undergoing change. A new practice management team was supported by Modality’s Senior Divisional Service Delivery Manager, who were instrumental in building a stable and secure team. This was echoed by staff who spoke positively about the leadership, who stated that the managers were approachable and responded to any concerns raised.

The service held regular management and staff meetings to ensure all staff members were aware of changes to service delivery. This was supported by notice boards communicating changes to all staff members. The practice had an equality and diversity policy and promoted equity to all people, including staff, with diverse needs and protected characteristics, such as sexuality (LGBTQIA+) age, religions, disability, race. Staff told us that leaders cared about their wellbeing and they felt supported.

Representatives from the Patient Participation Group (PPG) told us they felt the provider was open to constructive challenge and proactively made improvements to the service.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

There were systems in place to support staff to whistle blow or to speak with a Freedom to Speak Up Guardian if they had any concerns. Staff were aware of how to whistle blow and who the Freedom to Speak Up Guardian was and what their role was in supporting staff. The practice had established Freedom to Speak up arrangements with the Integrated Care Board.

The practice had carried out an independent and anonymous staff survey to allow staff to freely give their views on all aspects of the running of the practice. Staff felt that they could speak up and felt that their voice would be heard and acted upon.

The service had a diverse staff group and recognised the values and actively embraced the diversity of the workforce and the wider community. The service had a significant focus on staff wellbeing and had an enhanced induction and probation system to ensure new starters were well supported.

The service had a wellbeing Champion to support staff members and a social secretary to arrange social events for employees, which included summer BBQ and Christmas party.

We received feedback from staff members who described the culture of the service as “friendly,” “good team, works well together,” “open door policy, approachable and supportive,” “it’s like a family,” “amazing.” Staff told us that leaders were visible and they were listened to if they had a problem or a suggestion for improvement.

The service had clear responsibilities, roles, systems of accountability and governance which they used to manage and deliver good quality, sustainable care, treatment and support. They acted on information about risk, performance and outcomes.

Modality Partnership and management team had implemented robust governance systems to monitor and record delivery of services to people and ensure that people remained safe. They demonstrated a high level of organisational skills by having tools to efficiently monitor all aspects of the management of the service. For example, diary dates were in place for monitoring staff training with reminders sent before training became overdue. Electronic records were managed efficiently to be accessible and easy to understand. There was a comprehensive overarching risk assessment system in place to monitor risks to the service. For example, fire, legionella, Disclosure and Barring Service checks, immunisations, premises. These mandatory risk assessments were electronically diarised by the manager prompting when reviews were required.

Managers held regular clinical meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded actions arising from these meetings and shared these with staff.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Daily communication huddles were held first thing in the morning between the clinical and administrative team and clinical team huddles were held mid-morning. Processes were in place for appraisals and performance reviews for all staff. Staff knew how to access all required policies and procedures.

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 collaborated for improvement.

The service worked with other practices within their primary care network (PCN) to offer a wide range of services. For example, we saw evidence of collaborative working with the local primary care network (PCN) to achieve local response to challenges, enhance resilience and reduce the variation in the quality of service provision. For example, PCN childhood immunisation project to reduce barriers accessing health care and build trust of healthcare services within the community. To achieve the aims, the project planned outreach events to reach out to people. For example, flyers produced were interpreted into the four most common ward languages, Czech, Tigrinya, Urdu and Arabic. To support meaningful engagement the project worked with a community organisation which specialised in supporting women from ethnically diverse backgrounds, and single parents and children to create an equitable future. The PCN childhood immunisation project was led by the service’s equality and diversity lead.

PPG meetings were held in collaboration with practice staff representatives and demonstrated a commitment to engage with people and seek their views in shaping services to ensure people’s views are heard. We saw minutes of PPG meeting to support this collaboration.

The PPG had their own notice board in the waiting area and were actively encouraged by the practice to have their say in the media content on the board.

There were processes in place to work in partnership with key organisations and agencies to support the provision of care and joined up working. Staff told us they regularly went over and above for people by referring them to services within the community such as a health and wellbeing coach to support them to live healthier lives.

The service focused on continuous learning, innovation and improvement across the organisation and local system.

The service was an established training practice for medical students. Systems were in place to support trainees and students during their placements. Daily de-briefs with medical students were held and people were seen with the oversight of the service’s GPs. The lead GP at the service provided training videos via YouTube and other online media to support medical trainees. In addition, the lead GP produced health promotion videos posted on social media platforms on topics such as how to use the NHS App and launched the practice’s own WhatsApp channel.

The service used learning from patient feedback, significant events and complaints to continually improve the service they provided, and changes were made within the practice if needed.