Churchfields 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 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. Feedback we received from staff regarding the culture within the practice was positive. Staff told us there was an open and honest culture within the practice.

The practice 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. Staff told us leaders in the practice were approachable and responded to any concerns raised. The practice regularly assessed their leadership and management structures to identify strengths and development needs. They did this through a variety of methods such as appraisals, personal development reviews and patient feedback. 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 fostered a positive culture where people felt they could speak up, and their voice would be heard. Staff were aware of how to raise concerns and felt confident they would be listened to, and their concerns would be acted upon appropriately.The practice had established Freedom to Speak up arrangements with other practices in the primary care network.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. All staff had completed equality and diversity training. Leaders were committed to providing an inclusive and supportive working environment. They made reasonable adjustments to ensure all staff were valued.

The practice had clear responsibilities, 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. There were clear governance structures and processes within the practice. For example, policies were regularly reviewed and updated, and all staff were clear on their individual roles and responsibilities. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Staff took patient confidentiality and information security seriously.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The practice worked with external services and advertised additional services available to patients such as social prescribing, physiotherapy and speech and language therapy. The practice had an active patient participation group (PPG) which was supportive of the practice in driving improvements.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The practice had a quality improvement plan in place to help drive improvements to services. The leadership team supported the training and development of both clinical and non-clinical staff. As a GP training practice, they also supported the development of future clinicians.