The 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 service leadership, management and governance assured person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question as good. The rating remains good following this assessment.

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.

There was a mission statement across the service to provide a good quality service that was responsive to people’s needs. Staff spoken with knew about the ethos of the service. The provider had an understanding of the challenges and the needs of the patient population. There were clear responsibilities for clinical and non-clinical staff. There were arrangements to communicate between and within teams of staff at the service. Formal staff meetings had not occurred on a regular basis in the last 12 months, but a plan to address this was in place and recent formal meetings had been held. Staff questionnaires indicated staff felt that there was a positive, supportive culture at the practice. Staff demonstrated an understanding of equality, diversity and human rights, and they prioritised good quality and compassionate care.

Leaders understood the context in which they delivered care, treatment and support. The leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area. The provider monitored and acted upon data about outcomes for patients. They made improvements when required. Feedback from people who used the service was positive with regards to the capability and compassion of the staff and leadership team. We asked staff to complete a questionnaire to inform this assessment. Staff told us that leaders were visible and approachable. They felt supported by the leadership team and told us there was good communication from leaders and between teams.

Feedback from staff surveys showed that staff knew how to access policies and procedures and the nominated people to support them to speak out such as the whistleblowing policy and the Freedom to Speak Up Guardian. There were opportunities for staff to provide feedback on how the service was operating. For example, meetings were held, staff surveys circulated, and the provider told us how they encouraged staff to approach the management team with any concerns or ideas for improvements. Feedback from the staff surveys showed staff felt supported by the management team.

The provider valued diversity in their workforce. They told us how they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Reasonable adjustments were made to support staff to carry out their roles. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability. The practice had an equality, diversity, and inclusion policy.

Overall, there were effective arrangements for identifying, managing, and mitigating risks. This assessment has identified some areas for improvement regarding the management of patient care. There were processes to ensure that learning was shared from complaints and action was taken to improve the service and prevent a reoccurrence. We identified that improvements were needed to the management of significant events.

The provider carried out audits to review the quality of care and treatment provided and make changes if required. We reviewed a sample of audits and noted that these did not always provide an analysis such as a clear account of the findings and actions to be considered.

A clear management structure was in place with designated staff members who acted as leads for clinical and non-clinical areas. Staff roles, responsibilities and lines of accountability were clear.

We saw how change was discussed and implemented following feedback from people who used the service, staff and relevant stakeholders. Information was used effectively to monitor and improve the quality of care and treatment provided.

Staff could access all required policies and procedures.

There were arrangements in place for the availability, integrity and confidentiality of data, records, and data management systems and staff took patient confidentiality and information security seriously.

The provider worked in partnership with relevant external stakeholders, commissioners and partner agencies to provide and develop effective services. They worked with the Integrated Care Board to provide enhanced services such as minor surgery, avoiding unplanned hospital admissions and NHS health checks.

They worked collaboratively with the PCN. Services provided by the PCN included social prescribing, physiotherapy services, therapeutic services for children, young people and their families, mental health nurse appointments and health checks, women’s health, cancer support groups and services to promote ageing well. The services to support older patients provided by the PCN included providing enhanced health in care homes which had reduced hospital inpatient stays and Accident and Emergency attendance across the PCN over a 2-year period. This also included social events to reduce isolation whilst offering health checks and providing support and advice.

The practice had a Patient Participation Group (PPG) which had recently been re-established. We met with representatives of the PPG, and they told us the provider was working with them to identify people’s views about the operation of the service. The provider sought feedback from patients and reviewed external sources of feedback such as the national GP Patient Survey and the NHS Friends and Family Test. The provider took action to address any shortfalls identified. For example, following peoples feedback changes had been made to the appointment system.

There was a focus on continuous learning and improvement across the service. Systems for assessing the quality of the service and outcomes for patients were in place. For example, the provider was working on prescribing systems and processes to ensure this was meeting patient needs.

The provider worked collaboratively and in partnership with stakeholders to improve the experience of people who used the service and those within the locality. For example, the provider had recently worked with the PCN to offer a health screening day for refugee and asylum-seeking patients. The practice had hosted a mobile screening bus to proactively identify health concerns. The practice was in the process of applying for the learning disability friendly award. The provider had plans in place to set up a coffee morning to help socially isolated patients. They were also looking at assessing and improving services for lesbian, gay, bisexual and transgender (LGBT+) people.