Catterick Village 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 leadership, management and governance assured high-quality, person-centred care which 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 has changed to requires improvement.

The provider was in breach of legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Catterick Village Surgery had a shared vision, strategy and culture. This was based on transparency, equity, equality, inclusion, engagement and understanding the challenges and needs of its patients and community.

The practice promoted core values of openness, respect, compassion, and accountability.

Although not all staff felt they had contributed to the strategy, they knew the practice had a clear vision for the future.

The practice’s mission statement included the promise that, “We will work fairly and inclusively, ensuring our services are accessible to all, and we will maintain a professional, respectful environment for patients, visitors, and our team.”

Even if some things were not going well, the practice fostered a supportive learning environment with the aim of improving their services.

Staff told us there was a positive culture at the practice which ensured dignity and respect for patients.

We observed professional and respectful interactions between staff and with patients.

The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They embodied the culture and values of their workforce and organisation.

Staff felt supported by both their line manager and senior leaders. They told us managers were visible and approachable.

One staff member said, “I feel that the leadership within the surgery works well at all levels. I consider myself very fortunate to work in an environment where both the [job role] leadership and the wider practice leadership are exemplary.”

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

Leaders had an ‘open door’ policy. Staff told us leaders would welcome any concerns they raised. One staff member confirmed that, “Issues raised are always discussed.”

We did not observe any information in staff areas relating to the ‘Freedom to Speak Up’ (FTSU) process and relevant contact points. However, staff knew which practice leader was the FTSU Guardian.

The practice had an arrangement with the local Integrated Care Board enabling staff from Catterick Village Surgery to raise concerns with someone outside of their practice if they chose to.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for their staff.

Leaders told us reasonable adjustments could be made to support staff when needed.

Staff had completed appropriate training in equality, diversity and human rights.

Some policies contained an ‘Equality Impact Assessment’ to demonstrate they had shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations regarding the characteristics protected by equality law. Some policies also considered the potential needs of staff and offered the information in accessible formats. However, these considerations were not consistent across all the practice’s policies and procedures.

Catterick Village Surgery did not ensure clear responsibilities, roles, systems of accountability and good governance in all areas.

The provider had not fully established effective governance processes appropriate for their service. They did not have comprehensive oversight of health and safety matters relating to their premises. The practice had not completed appropriate risk assessments.

The provider had not maintained complete and detailed staff recruitment and personnel records.

The practice did not always operate in accordance with its own policies. Not all policies were clear about what staff should do, when and how.

The provider did not have a schedule of regular audits to ensure appropriate evaluation of their service, clinical and non-clinical tasks, and staff adherence to policies, procedures and best practice. They did not have a programme of regular clinical audits of prescribing that focused on improving patient care and treatment. Of the audits we reviewed, many were undated and lacked detailed findings and learning points.

Although there was a process for staff to report safety events, we found the practice did not formally analyse emerging themes and trends. Leaders did not have a system to track safety incidents or complaints raised to ensure all required tasks were actioned by an appropriate person and within a timely manner.

Practice leaders held regular discussions about governance, clinical and non-clinical issues, but key decision-making was not always fully documented or evidenced.

However, managers held regular practice meetings with staff to share learning and areas for improvement. Clinical staff discussed any patient concerns and emerging risks on an ongoing basis. Staff told us leaders and managers supported them well. Staff felt they could approach any colleague to ask a question if they were unsure.

Catterick Village Surgery understood their duty to collaborate and work in partnership so that services worked seamlessly for people.

The practice recognised an issue with a community partner organisation which was sometimes leading to inappropriate referrals for their patients. Leaders used a positive and proactive approach to resolve this. They investigated the issues, explored themes and trends, and implemented new protocols to assist staff to resolve future problems. Leaders also attended an in-person meeting with the organisation involved to discuss and resolve the issues and ensure a collaborative approach to learning and improvement.

The practice hosted medical students at various stages of their training. They also hosted Foundation Year 2 doctors on 4-month GP posts. Many of the doctors were military trainees with links to the local Catterick Garrison (Army base).

Leaders had good links with Newcastle University, Hull and York Medical School, and Northallerton Vocational Training Scheme which provides training for newly-qualified doctors specialising in general practice.

The practice focused on continuous learning, innovation and improvement. They encouraged creative ways of delivering equality of experience, outcomes and quality of life for patients.

We read examples of staff intervention and support for patients with complex needs. Staff worked with patients to overcome difficult scenarios to ensure safe, person-centred and compassionate care. Leaders shared learning from these interventions to drive staff awareness and improvement opportunities.

Staff worked collaboratively with relevant partner organisations to share key information and learning for the benefit of both staff and patients.

Catterick Village Surgery has been a training practice for many years. Leaders told us teaching and training forms part of the practice’s ethos and identity. Students and training doctors were supported to complete quality improvement projects (QIPs) to strengthen their own learning as well as support the continuous improvement of the service provided by the practice to its patients.

The practice held regular meetings which were attended by both clinical and administrative staff to ensure safety events (and other relevant incidents) were discussed and the learning shared with staff. Outcomes from any recent QIPs and audits undertaken were also shared with staff.

Some clinicians of the practice were GP Trainers with the Northallerton Vocational Training Scheme, thereby supporting the local GP speciality training programme.

All practice staff were involved in supporting students and training doctors. Administrative staff had a crucial role in ensuring all trainees had appropriate patients for their surgeries, and that patients were supported when they attended these.