The Old Court House 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 high-quality, person-centred care, supported learning and innovation, and promoted an open, fair culture.

At our last inspection in October 2016, using the old methodology, 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 practice had a shared vision, strategy and culture that focussed on learning and development which prompted trust and understanding. Staff listened to patient’s needs, complaints and suggestions and showed an understanding of equality, diversity and human rights in providing safe, compassionate care for the patient population. The staff understood the vision of the practice to meet the needs of the patient population and to review the care when these needs changed.

The service had 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 told us leaders in the practice responded to any concerns raised. We saw 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 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. The practice had not identified an official person for staff to approach within the practice and were in the process of developing this part of the policy. In the meantime, staff could talk to either the practice manager or one of the partners.

The service valued diversity in the workforce. They 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. Adjustments had been made to ensure all staff were valued. Team building and social events occurred and future events were planned.

The service had clear responsibilities, roles, systems or accountability and good governance. They used this to 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. Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff received regular appraisals and performance reviews. Governance processes were established that were appropriate for the service. Staff could access policies and procedures on both the shared computer system and also in their own policies folder which they updated when needed. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Regular meetings were also held between teams, for example the reception and nursing team met regularly to discuss appointments for areas such as cervical screening and immunisations. 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 shared information and learning with partners and collaborated for improvement. The provider worked with other practices within the PCN to offer extended access, and flu and Covid vaccination programmes.

The practice prioritised patient clinical care and needs by ensuring that allied health professionals were used effectively in response to patient feedback. Learning was shared with other practices and the wider PCN. The practice nurse worked in collaboration with other practice nurses across the local area. The practice actively engaged with their PPG.

The service focussed on continuous learning, innovation and improvement across the organisation. 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. This focused on improving patient access to appointments and the cervical and childhood immunisation programmes. Quality improvement audits were carried out regularly.