The Green Surgery Also known as The Green & Fir Road Surgeries

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 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 service had a shared vision, strategy and culture. Staff reported that the practice had been thriving, friendly and patient‑centred. Staff explained that they worked closely together, valued one another’s strengths, and aimed to ensure every patient felt listened to, respected, and well cared for.

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 was aware of the projected increase in the local population and was working with partner agencies to address future challenges. For example, staff reported that the population attending the branch site faced additional pressures due to socioeconomic deprivation. They explained that support was provided through community support workers, interpreting services, social prescribing, and links with voluntary and council services.

The service 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. Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff told us that managers had “open door policies” and that they felt able to approach them for support at any time without hesitation. They also reported that leaders promoted regular information sharing and collaborative problem‑solving. Staff described a leadership team that supported their wellbeing and professional development and promoted an open and learning‑focused culture where learning was encouraged when relevant to their role.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and reported leaders actively promoted a culture of openness and empowerment, encouraging staff to speak up and valuing their contributions. Staff told us they were confident their voices would be heard. When concerns were raised, staff reported that leaders investigated them sensitively and confidentially, shared lessons learned and took action to prevent recurrence.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures were in place to support equality and diversity, and staff reported that leaders took steps to ensure they felt supported and able to perform their roles effectively. They also said the organisation was responsive to individual needs and made reasonable adjustments where required. These included adapting workspaces, providing ergonomic or accessible equipment, and ensuring staff with health conditions had suitable tools to carry out their duties safely.

There were arrangements for identifying, managing, and mitigating risks, however during the onsite visit, we identified some gaps and areas requiring improvement. Although they had an up‑to‑date water testing certificate, the service did not have a Legionella risk assessment or a Health and Safety risk assessment in place to demonstrate that risks had been assessed. We also found that key safeguarding information was incomplete, as the practice did not have a Female Genital Mutilation (FGM) policy in place.

We noted that mandatory training was not being consistently monitored or completed in line with the practice’s own policy. As an example, the policy required all staff to complete information governance and cyber security training, yet information governance training was missing for most non‑clinical staff, and cyber security training had not been completed by any staff, including clinical colleagues. There was no evidence that these mandatory requirements had been monitored.

We also found that the practice had not completed two full‑cycle clinical audits.

We raised these issues with the practice during the inspection. Shortly afterwards, they confirmed that staff had completed information governance training. The practice also advised that they would review their policy and update the training matrix to ensure it aligned with current intercollegiate guidance and their own policy.

Despite these concerns, leaders and managers supported staff, and all staff we spoke with were clear about their individual roles and responsibilities. Managers met with staff annually to complete appraisals; however, we noted that the GP received an appraisal every two years. Managers held regular practice meetings to discuss clinical concerns and emerging risks, recording actions and sharing these with staff. Staff took patient confidentiality and information security seriously.

The service 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. Staff and leaders, we spoke with were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Staff had made adjustments to improve coordination of their service with community healthcare services, including regular meetings centred on the care of those at higher risk of hospital admission. Staff reported that they routinely engaged with the GP liaison contacts at the local hospital to discuss patient matters and share learning. They also stated that they had participated in multidisciplinary meetings, such as Proactive Anticipatory Care (PAC), which were designed to prevent crises, reduce hospital admissions, and support people to remain independent at home.

They have a Patient Participation Group (PPG) in place to engage with the patient population and gather views and suggestions. Staff reported that even the turnout was low, they continued to offer opportunities for patients to engage and provide feedback, and they remained open to hearing from individuals who preferred to approach them directly.

The service focused on continuous learning and improvement across the organisation. The practice had a quality improvement plan in place to help drive improvements in services. Representative from the PPG reported that the practice involved them in developing the plan. For example, when the new phone system was introduced, the practice sought feedback from PPG members and other patients. They were asked how the system felt to use, what worked well, and what could be improved. This feedback was reviewed and used to understand the overall quality and user experience.

All staff were encouraged to put forward and test out new ways of working, and we saw examples of this during our inspection. Staff told us that the practice had introduced a range of enhanced services to broaden the support available to patients. They explained that developments such as anticoagulation management, expanded diabetes clinics, and more flexible phlebotomy sessions had improved access to care and encouraged ongoing innovation. Staff said these improvements also helped reduce health inequalities, particularly for patients with greater levels of need.