Church View 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 service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and 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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy.

The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

Staff expressed enjoyment in their roles and valued the collaborative environment. Regular team meetings were held to share updates and promote open communication across the service. Records of meeting minutes and actions were stored and accessible to all staff on the service’s electronic system.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

All staff we spoke with were clear on their individual roles and responsibilities.

Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. However, oversight of staff training was not fully embedded as we saw that not all staff were up to date with required training.

The service had established governance processes. The service had identified policies and procedures, which staff could access and were requested to provide acknowledgment of having read and understood them. This included the management of complaints. The service responded to complaints appropriately, in line with regulations and had implemented changes where required. For example, leaders reviewing data in relation to accessing the service to inform decisions made regarding changing the online service and listening to call recordings where complaints have been raised concerns in relation to staff conduct.

GPs and the practice manager held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. They clearly recorded any actions that arose from these meetings and shared these with staff.

Leaders discussed quality and governance in relevant meetings, and all staff had access to this information as appropriate to their respective roles.

Clinicians were available to support enquires from staff and met regularly with secondary care specialists to discuss vulnerable people, complex cases and share expertise. This approach reinforced a strong culture of openness, learning and improvement. Staff told us they felt supported and empowered, and that leaders were approachable and responsive.

Staff took people’s confidentiality seriously and stored their information securely.

Staff were aware of the requirement to submit data and notifications to external agencies as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.