Bredon Hill 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 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 practice 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 practice promoted a positive, compassionate, listening culture that supported trust and understanding between staff and patients using the service. Learning and development were supported. Staff expressed how the practice was a friendly and supportive place to work. Staff shared a common aim to do the best they could for patients and strived to provide safe, high-quality care.

The practice 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 in the practice were approachable, responded to all concerns raised and 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 practice fostered a positive culture where staff felt they could speak up and their voice would be heard. The practice had a Freedom to Speak up policy, however not all staff knew who the Freedom to Speak up Guardian was. There were no arrangements for staff to speak up externally if they did not feel comfortable speaking up within the practice. Most staff raised concerns with their manager and felt confident it would be dealt with appropriately.

The practice 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 equality and diversity. We reviewed staff training and found that only 2 out of 5 staff had completed their equality and diversity training. Staff feedback about the culture of the practice in the context of workforce equality was positive. Leaders made reasonable adjustments to support staff to carry out their roles well.

Staff told us they were clear about their responsibilities, roles, systems of accountability. The provider had established governance processes that were appropriate for their service to deliver good quality, sustainable care, treatment and support. Leaders were in the process of improving their policy schedule to make it more streamlined and plan to store them in the same place to make them more accessible to staff. Clinical concerns and emerging risks were discussed during team meetings and the minutes were shared with staff to ensure the relevant information and actions were acknowledged and addressed. Staff took patient confidentiality and information security seriously.

The practice understood their duty to collaborate and work in partnership to support care provision enabling services to work seamlessly for patients. Staff and leaders engaged with people, communities and partners to share learning with each other and to promote continuous improvement. Working alongside practices in the primary care network, enabled the practice to identify new or innovative ideas that could lead to better outcomes for people. For example, some staff at the practice carried out research about attention deficit hyperactivity disorder (ADHD) and the services available to help these patients. This information was shared amongst the Primary Care Network.

The practice focused 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. Staff learned from significant events and complaints to continually improve the service they provided. All staff were encouraged to put forward and test out new ways of working.