Market Square 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and 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 very clear shared vision, strategy and culture.This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders demonstrated an exceptional understanding of the challenges and the needs of people and their communities.

The practice's mission was to improve quality of life by providing proactive, preventative and person-centred healthcare. Through its Right Care, Right Person, Right Time approach, the practice committed to delivering high-quality care that was safe, effective, caring, responsive and well-led.

The practice evidenced its adherence to its mission statement through its robust triage processes, ensuring patients saw the right clinician to meet their needs. This was underpinned by a responsive and accessible service, which was closely overseen by the duty doctor and GP partner. A care home representative explained that the responsiveness of the GP meant that they were able to avoid using 111 and emergency services, ultimately keeping residents out of hospital when this was the best course of action.

The whole team were committed to delivering good, accessible and safe care. Staff and leaders explained how they would cover shifts at short notice and described the open-door policy, which meant they were confident asking for care and support.

The surgery had recently experienced changes in its partnership structure and had navigated this transition effectively and with due consideration of staff and patients. The practice’s business plans considered the evolution of the partnership moving forwards, alongside the changing commissioning landscape and local ambitions. Risks were documented, with supporting action plans and mitigations to respond to these risks.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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, systems of accountability and good governance. 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.

Staff we spoke with were clear about their individual roles and responsibilities, whilst taking a flexible approach to ensure changing day-to-day demands were met.

Leaders proactively supported staff and regularly met with them to complete appraisals to identify training needs and hold career development conversations. A GP Registrar explained how their learning was structured to meet their own evolving needs, and how the clinical team had provided teaching and guidance when they had identified an area of growth.

The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service. Staff could access all required policies and procedures, which were kept up-to-date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed significant events, complaints, patient safety alerts and changes within the service.

Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations. Staff submitted data and notifications to external agencies as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.