The Brimington 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 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.

Staff were actively involved in shaping the practice's vision and strategy through collaborative efforts. To foster engagement, a competition was held for staff members to develop the practice's mission statement, with the winning entry being formally adopted. The practice was aware of the projected increase in the demand for GP services and was working with partner agencies to address future challenges. For example, the estates team at the Integrated Community Board (ICB) to create 2 additional clinical rooms within the practice and relocation of the upstairs waiting room.

Staff were very positive about the culture within the practice and described it as very open, supportive, friendly and transparent.

A representative for the Patient Participation Group (PPG) told us that the practice had a culture of actively listening to them and being honest when they were not able to do things.

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.

Staff told us leaders were always very approachable and responded to any concerns raised. They told us leaders actively welcomed staff feedback and listened and acted on this and were visible within the practice. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices 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 practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns with the Freedom to speak up guardian or champions.

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 and systems of accountability. 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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all of the required policies and procedures. Managers held regular practice 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 confidentiality and information security seriously.

The provider had established governance processes however, they were not always fully effective. For example, arrangements around medicines management and infection prevention and control.

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

The provider worked with other practices within their primary care network to offer extended access. They worked in partnership with the Aging Well team to support people living in care homes and participated in community events such as the village festival. There was a book stall in the waiting room which raised money for the local hospice, and they had held cake sales to raise money for The Douglas MacMillan cancer charity.

Leaders had invested in developing diverse networks at local and national levels. The service proactively supported the lesbian, gay, bisexual, transgender, and queer and other sexual orientations and gender identities (LGBTQ+) community and had won an award for making the practice a safe place for the LGBTQ+ community to attend. There was a dedicated page on the practice’s website to provide local and national support and guidance for this population.

The service had collaborated closely with local shops, businesses and the parish council to install a publicly accessible defibrillator on the exterior of the practice building for the benefit of the local community. Whilst the practice managed the maintenance and regular checks of the device, community members could access it directly by contacting the 999-emergency service line when needed.

The service worked in partnership with the care homes where they provided care and treatment, feedback from the care homes was very positive. One representative told us there was a give and take relationship with the practice and they worked together to improve outcomes for people living in the home.

The service had established a strong working relationship with their Patient Participation Group (PPG). A representative of the PPG told us they felt very valued by the practice and that their concerns were listened to and acted on where possible. For example, the rearrangement of chairs in the upstairs waiting room to ensure everyone could clearly see the electronic call board. The PPG worked in partnership with the practice to review and act on comments received through the Friends and Family test.

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.

The service used learning from significant events and complaints to drive improvements within the practice. The practice had analysed the feedback from the National GP Patient survey. Analysis showed that the overall feedback was very good, and they were above the national averages in most areas. They recognised they needed to improve access to their website which they expected to achieve through the introduction of a recently installed IT system.

The practice was a research practice and were members of the NIHR East Midlands RDN Research Site Initiative (RSI) Scheme. At the time of our assessment, they were participating in various research projects for example, mapping sweet sensing in type 2 diabetes and a winter pressures study which included regular surveys over the winter months to assess operational pressures. The practice participated in the ReSTORe Stroke Study, a research initiative designed to evaluate exercise-based rehabilitation support for recent stroke patients. Participants were assigned to 1 of 2 intervention groups, either online or in-person rehabilitation, with before and after questionnaires used to assess the impact and effectiveness of each approach.