South Milford 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

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

This service scored 79 (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.

Most staff felt they contributed to the development of the practice vision and strategy. The practice had undertaken a staff survey in 2024 which showed 79% of staff felt able to make suggestions to improve their work at the practice.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. This included bidding for funding to extend and refurbish their current estates.

Staff feedback we received was positive about the culture of the practice. All staff we spoke to felt positive about working at the practice.

The practice had recently experienced challenges in turnover of staff in administration areas, but staff felt positive about the future and current staffing levels.

Staff described good working relations and a service that was clear on its function to work in the interests of patients, providing the best possible experience.

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 did so with integrity, openness and honesty.

The provider had recognised that staff communication could be improved and had set up a staff participation group. The practice had introduced a new induction process for new staff which had been identified as a priority from the staff participation group. There was a dedicated noticeboard used to celebrate the successes achieved by staff.

Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area.

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

The practice had established Freedom to Speak up arrangements with other practices in the PCN. Staff were aware of how to raise concerns.

Staff questionnaires highlighted that staff were aware of Freedom to Speak up arrangements.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they felt supported, were treated equally, and were free from bullying and harassment.

Policies and procedures to promote diversity and equality were in place. A review of staff training showed that staff had completed training on equality and diversity.

The service 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. Managers met with staff regularly to complete appraisals and performance reviews.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures.

Risk assessments had been carried out but some processes had not been actioned or given practical timescales. For example, the replacement of non-lever tap risk assessment was to be actioned by 2035. The provider confirmed this would be reviewed earlier.

Managers held regular practice meetings with staff, during which they discussed 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 service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The provider worked with other practices within their PCN to offer additional services such as extended hours for cervical screening and pharmacist appointments as well offering a paramedic home visiting service.

The practice was supported by an active PPG. The PPG met every 3 months at the practice; they alternated meetings between the main site and two branch sites. They had arranged events such as digital inclusion events and visits from the PCN.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice and research.

The practice had a Compliance Lead to drive quality improvement. They had focussed on the appointment system and introduced a clinically approved signposting toolkit for care navigation to support safe, consistent and clinically approved signposting by the administration staff.

The practice had invested in dispensing technology and used technology that was electronic prescribing system (EPS) compliant in the dispensing of medication to improve safety, efficiency and patient experience and recorded and documented on their clinical system. The software recorded dispensing data. The staff were very positive about this. As a result of this software dispensing errors had reduced.

The provider had invested in AI technology and used document management software which automatically captured patient information from patient letters and correspondence and documented on their clinical system.

All staff were encouraged to put forward and test out new ways of working.