Fell Cottage Surgery

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• 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. This was based on transparency, equity, equality and human rights, diversity and inclusion and engagement. Leaders demonstrated a good understanding of the challenges and needs of people and their communities and worked well with partner agencies to support people effectively.

The practice had a comprehensive 5-year business plan outlining its development objectives and the actions required to achieve its aims, including identified areas for improvement. These objectives focused on access, compliance and safety, operational efficiency, and workforce sustainability, including the development of internal leadership capacity and succession planning.

Leaders clearly recognised the importance of staff wellbeing in delivering positive outcomes for patients and actively promoted this across the service. Investment in learning and development was evident for all staff, supporting continuous improvement and best practice.

Values were embedded into everyday practice, fostering an open and respectful culture. Staff were confident to raise concerns, share ideas, and contribute to learning and improvement. They were highly motivated and consistently reported strong support from both leaders and colleagues. Staff described feeling valued, listened to, and recognised for their contributions.

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. It was evident that patients were at the heart of everything the practice did, and leaders demonstrated the importance of staff wellbeing to support them in maintaining good outcomes for patients. Staff told us managers were approachable, encouraged open communication, welcomed feedback, and responded constructively to identified concerns.

Leaders had maintained oversight of service quality priorities and risks. There were regular management and staff meetings to ensure all staff members were involved and aware of changes to service delivery as part of the team.

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 internally and with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The practice had an open culture where staff felt confident to speak up about any concerns. Staff reported that their views were heard and that they felt safe raising issues without fear of negative repercussions.

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 to promote diversity and equality were in place. 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. We saw and heard of no concerns with regards to workforce equality at any level including the recruitment of staff.

Adjustments had been made to ensure all staff were valued, for example adjustments to accommodate flexible working where appropriate, were in place.

The service had clear roles, responsibilities, and systems of accountability, and for the most part demonstrated effective governance. They used these to manage and deliver good quality, sustainable care, treatment and support. Leaders used relevant information on risk, performance, and outcomes to inform decision‑making and shared this information appropriately and securely when required.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff described leaders as approachable, with an “open‑door” approach, and reported that managers were responsive and available to provide support. Managers met regularly with staff to complete appraisals and performance reviews.

Staff could access all required policies and procedures and understood the importance of patient confidentiality and information security.

Managers held regular practice meetings with staff, where they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and shared with staff to support learning and improvement.

The provider had established governance processes that were appropriate for their service together with named leads in place for key areas. Recruitment processes were effective, and appropriate pre‑employment checks were completed for new staff. However, oversight of non‑clinical staff immunisations was not fully in line with current guidance.

During the assessment, we identified gaps in leaders’ oversight of the newly implemented online staff management training system. This made it difficult to establish whether mandatory training had been completed in accordance with the practice’s training policy. We also found that not all Patient Group Direction (PGD) authorisations were fully in place. A PGD is a written, legal framework in the NHS allowing registered health professionals (e.g., nurses, pharmacists) to supply/administer specific medicines to pre-defined groups of patients without a doctor's prescription. In addition, the practice did not have a local risk assessment in place for medical emergencies. However, we noted that leaders had recently discussed this and took action to address the issue following the assessment visit.

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.

The practice was part of the local GP Alliance Additional Roles Reimbursement Scheme (ARRS) providing additional speciality to the service such as pharmacy, social prescribing, physiotherapy and mental health.

The provider worked with other practices within their primary care network to offer extended access. Flu and COVID-19 vaccination programmes were delivered autonomously. Staff worked closely with community healthcare services, with staff taking part in regular multidisciplinary meetings to support coordinated and integrated care.

The practice engaged with the Integrated Care Board (ICB) primary care and their medicines management teams. The practice hosted trainee doctors to obtain experience of general practice.

The provider held an Armed Forces Veteran Friendly accreditation. This is a recognised program run by the Royal College of General Practitioners (RCGP) and NHS England for providing better care for veterans.

The practice had an established and active Patient Participation Group (PPG), which met in person at least 4 times a year. Meetings were attended by the practice manager and other relevant staff, as appropriate to the subject areas covered.

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 practice had an established business plan outlining strategies to drive improvements and efficiencies and apply best practices to enhance patient care. Areas outlined included access, digital transformation, workforce and leadership development and staff wellbeing.

The majority of patient feedback was generated on a monthly basis from the Friends and Family Test and was largely positive. Staff regularly reviewed feedback from patients and the wider community to inform, shape, and evaluate new ways of working. For example, patients commented that there was too much information displayed in the waiting room, which led to displays being streamlined. Additionally, patients highlighted that they did not like the results letters wording, so a more user-friendly, accessible version has been adopted.

Leaders actively responded to staff feedback, to implement changes and drive continuous improvement in service quality. Actions taken in response to staff feedback included the introduction of a staff wellbeing newsletter, the provision of new chairs, adjustments to rotas and appointment scheduling to improve patient access and availability, revisions to the annual leave process, and the development of an outdoor quiet space for both staff and patients.

The service was a training practice for post-graduate doctors entering general practice, including newly qualified doctors in their foundation training. It was also a teaching practice for medical and pharmacy students.