Testvale Surgery Also known as Dr Entwisle and Partners

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 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 and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges. They recognised the importance of collaborative working to enhance care for their local community due to their demographics.

All staff contributed to developing the service’s vision and strategy, which was kept under review. Staff we spoke with were proud to work for the service and shared a commitment to delivering high‑quality care. The service promoted a culture of learning and development, offering opportunities such as leadership courses and specialist training, including asthma and diabetes management.

During the inspection, CQC received 14 staff feedback surveys. All respondents said the service had a clear vision for the future and described a positive, supportive, and inclusive culture, where they felt well supported by clinicians and leaders.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was a clear staffing structure, and staff understood their roles and responsibilities. Staff had access to line managers and felt able to seek advice and guidance when needed. Staff told us leaders in the service were approachable and responded to concerns raised. Staff also told us leaders modelled the values of the service.

People who used the service were at the centre of the service’s work. The leadership team worked with other services in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had an internal Freedom to Speak up guardian, as well as external Freedom to Speak up arrangements with the local integrated care board (ICB). Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect. There were posters throughout the service highlighting who the Freedom to Speak up guardians were and how to contact them.

Staff told us there was an ‘open door’ policy and leaders welcomed feedback for service improvements. The service had a zero-tolerance policy in relation to the abuse of staff, with systems to protect people and minimise the likelihood of reoccurrence.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. There were policies and procedures to promote diversity and equality to support staff and people who use the service with different backgrounds and needs. 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. Leaders upheld a zero-tolerance policy for discrimination, ensuring any concerns between staff or with those using the service were promptly addressed. There were no reported concerns relating to discrimination in the service.

Leaders recognised the importance of career progression and actively promoted staff development, offering equal opportunities. For example, a member of the administrative team expressed interest in phlebotomy, completed phlebotomy training and worked in both roles within the service under 2 separate contracts. Staff reported they felt valued, respected, and included, and noted that ongoing development opportunities were provided irrespective of their background.

Adjustments had been made to ensure all staff were valued. For example, reasonable adjustments were in place for staff to work flexibly around other commitments, such as childcare or other caring responsibilities. Leaders promoted staff well-being by organising social events, facilitating positive relationships among employees and supporting a collaborative workplace culture.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews. There was a clinical supervision in place for non-medical prescribers, and we saw evidence that regular, documented clinical supervision sessions were taking place.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

A business continuity plan was in place, providing staff with clear guidance to follow in the event of system failures. This included detailed actions for managing emergencies such as power outages, environmental hazards, severe weather, and staff sickness. An incident involving the simultaneous loss of IT services and issues with web-based phone lines prompted the team to refer to their business continuity plan. The plan was not fully followed at the time and staff were uncertain how to proceed, so management provided further training to the administrative team and ensured the plan was clearly displayed and accessible.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with the other service within their primary care network to offer flu and covid vaccination programmes. Staff and leaders worked collaboratively with people and partners, sharing ideas and information to improve the quality of the service.

The service was aware of the needs of the local community and used this to improve outcomes for people by tailoring services to the local needs. 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.

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 contributed to safe, effective practice and research. All staff were encouraged to put forward and test out new ways of working, and we saw examples of this during our inspection.

The service had a quality improvement plan in place to help drive improvements in services. For example, one focus was on improving the phone system. The phone system was upgraded to help improve staff safety and access for people who used the service by adding queue monitoring, call-back, and call history features.

In response to demand in long-term condition management, the service had introduced an innovative blood pressure clinic, led by its patient participation group (PPG). Trained PPG members conducted blood pressure checks and guided people on appropriate next steps based on their readings. Clinicians regularly reviewed these results to ensure that no abnormal findings were overlooked.

The service worked closely with the primary care network (PCN) mental health team which provided a dedicated multidisciplinary service. The team included wellbeing assessors and psychological therapists, supported by a GP lead from the service, and held weekly multidisciplinary team (MDT) meetings to coordinate care and provide a clear single point of contact for people. This service offered timely, short‑term interventions and managed up to 25 referrals a week, helping reduce GP workload and ensure people were directed promptly to appropriate support. Leaders told us that this mental health service, developed under the guidance of the service’s mental health GP lead, was innovative and represented an achievement of which they were extremely proud of.