The Bucklebury Practice Also known as Chapel Row 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. There were concerns identified regarding the management and oversight of prescription stationery. The provider demonstrated a commitment to improvement and responded positively to the inspection feedback, making significant changes to strengthen governance arrangements.

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 provider 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.

Leaders and partners demonstrated a positive, compassionate culture, recognising the challenges of the local population. There was strong teamwork and shared commitment to delivering high quality patient centred care.

The practice recognised staffing challenges within the reception team and was actively working to recruit additional staff.

The provider 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.

Staff described the leaders as approachable, visible and responsive. However, staff indicated that communication within the practice could be improved to support greater clarity, consistency and engagement across teams.

Leadership resilience was evident as the practice navigated a challenging period over the past year during which two of the three partners were unavailable. Despite these challenges the practice demonstrated effective leadership and maintained continuity of services for patients.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. However, we noted that the practice did not currently have a named freedom to speak up guardian in place on their whistleblowing policy. However, the practice was responsive to this feedback and was actively working towards establishing this role to further support staff and provide additional avenue for raising concerns.

The provider 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.

Staff we either spoke with or received questionnaires from; told us they felt supported within the practice. They described the working environment positively and felt they were able to approach leaders and managers with any concerns, questions or issues they needed to discuss.

Staff told us they were encouraged to develop within their roles, and training opportunities were available. Policies and procedures to promote diversity and equality were in place. However, we identified a few staff members had not completed their required equality and diversity training.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

We noted complaints outcomes were used to strengthen governance processes and support continuous improvement across the practice.

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 annual appraisals.

Staff could access all required policies and procedures. Managers held regular practice meetings with staff and recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The PPG members described the practice as open and honest, with appropriate sharing of learning from complaints and incidents. They suggested communication between the practice and the PPG was effective and they were shared regular updates on practice developments.

During the inspection, we identified gaps in the mandatory training records for both clinical and non-clinical staff, and systems for the management and monitoring of security of prescription stationery.

We also noted that some of the concerns identified in relation to mandatory training records were attributed to the transition between training platforms which took place last year. This change resulted in some training records not being successfully transferred or retained during the migration process.

The provider was highly receptive to the feedback provided during the inspection and responded promptly to the concerns identified. Following the inspection, the provider submitted a comprehensive range of action plans, risk assessments, standard operating procedures (SOPs), policies and supporting documentation. These documents showed that the provider had taken steps to strengthen recruitment processes, improve oversight of mandatory training, and introduce clearer controls for the management of prescription stationery. The comprehensive response demonstrated a willingness to address the concerns raised and to strengthen governance arrangements to reduce the risk of recurrence.

We have asked the provider to continue to take action to strengthen governance arrangements in relation to mandatory training oversight and management of prescription stationery to ensure effective systems are in place to monitor and mitigate risk.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. They worked with other practices within their primary care network to offer extended access.

The practice worked in partnership with the Patient participation group (PPG) to support service development and improvement. The PPG met regularly with GP partners and the practice manager, providing a forum for open discussion, shared learning and patient feedback. Members told us they felt listened to and valued and gave examples of where their views had informed changes to the practice, including the dispensary redesign and online access and triage model. The PPG also shared wider community intelligence, helping the practice understand the population needs and plan for increasing demand.

The service 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 contribute to safe, effective practice and research.

We noted that the GP partners worked with reception as part of the duty doctor team. We were informed that this model was used to continuously identify improvements in access and to consider the wider demands on the service in order to better support the needs of the local community.

We saw a positive culture of learning and continuous improvement within the practice. For example, we identified area of improvements in the dispensary. The practice responded promptly and proactively, taking immediate action to address the issues identified. They introduced revised processes, strengthened policies, and implemented additional governance measures to reduce the risk of recurrence. This demonstrated the practice’s commitment to learning from feedback and continually improving the quality and safety of the services they provide.