Church Lane 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; supported learning and innovation; and promoted an open, fair culture. 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. Leaders demonstrated a commitment to continuous improvement, using feedback from people using the service, families, and staff to inform service development. The practice was a training practice and demonstrated a strong education and learning ethos. The practice engaged positively in the assessment process and was responsive, proactive and acted immediately on feedback.

At our previous inspection, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 71 (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.

The practice’s mission statement and values had been recently reviewed and revised in collaboration with staff. The mission of the practice was to provide healthcare that is not only efficient and informative but also deeply human. This was underpinned by the values of Compassion, Teamwork, Professionalism, Patient-Centred Care, Efficiency, Inclusivity, Communication and Growth. Some staff told us how they had been part of creating the new mission statement and gave examples of how they felt they lived the practice’s values in their roles.

The practice had an experienced leadership team in place. Leaders we spoke with were knowledgeable about issues and priorities of their patient demographic and what work was needed to drive patient outcomes. Staff told us that managers were visible and approachable and that they felt supported by them. Staff felt they worked well as a team to manage the day-to-day workload.

The practice fostered an open culture and encouraged staff to speak up if they had concerns or ideas for improvement. Staff told us they felt safe raising issues without fear of negative consequences. Regular team meetings and supervision sessions gave further opportunities for staff to talk openly about their experiences.

There were policies in place for Freedom to Speak Up and Duty of Candour. There was a nominated Freedom to Speak Up Guardian and all staff knew who this was. Staff also had access to an external Freedom to Speak Up Guardian.

Policies and procedures to promote diversity and equality were in place. Training in equality and diversity was provided, and staff understood the importance of creating an inclusive environment both within the workplace and in the care they delivered. There were systems and processes in place to support the safety and well-being of staff. Overall, staff reported a positive culture at the practice. Some staff gave examples of support they had been given by the practice, both personal and professional.

The practice had system and processes to support good governance although we found some gaps around medicines management and the management of some patients with long-term conditions, safeguarding, safe environments, safe and effective staffing and infection prevention and control (IPC). The practice was extremely responsive to feedback during the assessment and acted immediately on areas raised as a concern. This included enhancing current systems, updating policies, or providing an action plan.

There were nominated clinical and non-clinical leads for key areas whom staff could contact for advice and support. For example, safeguarding of adults and children, complaints and IPC. Staff we spoke with were clear about their role, responsibilities, and how they interacted with other staff. They told us they had access to policies and procedures to support them within their role and attended regular meetings where discussions about the practice, such as complaints and significant events, were discussed.

There were processes in place to ensure data management and security. The practice was registered as a data controller with the Information Commissioner’s Office (ICO). Staff took patient confidentiality and information security seriously. Staff we spoke with told us they followed the practice’s confidentiality policy when discussing patients’ treatments. This was to ensure that confidential information was kept private, for example, patient information was never on view and computers were locked when not in use. We saw that all staff had undertaken information governance and data security awareness training.

There was a business continuity plan in place, which included supplier and staff contact details.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for patients. We saw the practice attended regular primary care network (PCN) meetings. Leaders told us they used a range of methods to gather patient feedback. For example, from the National GP Patient Survey, Friends and Family Test (FFT), complaints and compliments. Staff told us they could provide feedback through meetings and annual appraisal.

The practice had a small Patient Participation Group (PPG), which attempted to convene twice a year. We saw that the last meeting was held in January 2025. We saw evidence that the practice was actively promoting the PPG to encourage patients to join to make it more representative of the practice population.

Staff were supported to undertake further training and acquire new skills. Staff told us they were provided with adequate training for their roles, and some staff gave examples of how they were encouraged and supported with professional development.

There were systems and processes for learning, continuous improvement and innovation. The practice engaged with the neighbouring practices in local current and future initiatives which included the Primary Care Network (PCN) (an approach to strengthening and redesigning primary care to focus on local population needs).

The practice had a comprehensive schedule of clinical audits and quality improvement initiatives, and a range of data was collected and reviewed to improve service delivery and drive outcomes for the patient population. For example, we saw reviews of incidents, patient feedback, audits and patient outcomes such as prescribing.

The practice was a training practice and demonstrated a strong education and learning ethos. The practice took pride in their role as a training practice and supported GP registrars and foundation year doctors, as well as a pharmacy technician apprentice. In addition, the practice supported work experience student placements for those interested in pursuing medicine, as well as the apprenticeship scheme for reception and administrative roles.