S H Vaghela & Dr V N Patel Also known as The Old 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 the practice’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good.

At this assessment, we focused on 2 quality statements relating to the key question Well-led: Shared direction and culture and Governance, management and sustainability.

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 shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

Staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The practice was aware of local challenges which affected the service and worked with partner agencies to address them challenges.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development. The feedback we received from 7 members of staff supported this.

Staff feedback included:

• “Good management; amazing team.”
• “Friendly and open.”
• “The culture is positive, professional, and collaborative. There is a strong emphasis on patient safety and quality of care. Staff feel comfortable raising concerns and the working atmosphere is respectful and supportive.”
• “Excellent mentor. A good team to work with.”

To increase patient involvement, the practice had re-established the Patient Participation Group (PPG), which had become inactive during the COVID-19 pandemic. It comprised of 8 patients and had met once recently, with a future schedule of meetings every 3 months. From the meeting minutes, we saw plans were in place to increase the number of responses to the National GP Patient Survey. The PPG was invited to consider and propose any changes that might improve service provision and patient experience. Practice staff had suggested the introduction of a Saturday morning clinic and coffee event where early dementia cognitive testing would be carried out. This had been agreed by the PPG and plans for its implementation were moving forward. We spoke with a representative of the PPG who was positive regarding the practice’s engagement.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The practice had clear responsibilities, roles, systems of accountability and good governance. It used these to manage and deliver good quality, sustainable care, treatment and support. It acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We received feedback confirming staff members were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews.

The practice had put in place a suite of governance policies in relation to the quality statements we reviewed during this assessment. The practice sent us a wide range of the policies which we saw were regularly reviewed, updated to reflect latest guidance and shared with all staff. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously. Staff submitted data and notifications to external agencies as required.

We saw evidence of staff receiving governance training relevant to the roles and responsibilities, such as Information Governance, Caldecott and Confidentiality, Accident Reporting, Consent, Freedom to Speak Up, and the Duty of Candour.

We saw evidence that staff submitted data and notifications to external agencies as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.