The Summerhill 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.

Leaders and staff at The Summerfield Surgery shared a clear vision and culture in listening, learning, and mutual trust. Leadership was visible, knowledgeable, and supportive, actively fostering staff development. Staff reported feeling empowered to provide feedback and described a workplace culture that promoted equality and was free from bullying or harassment. Roles and responsibilities were well understood across the team. Managers engaged with the local community to deliver high-quality care and demonstrated openness to innovation. A culture of continuous improvement was evident, with staff supported through time and resources to explore and implement new ideas.

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 based on providing a good quality, friendly and approachable service equal to all, regardless of age, race, sex and disability.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The practice demonstrated an understanding of the challenges and evolving needs of the local population, including anticipated demographic growth and the importance of succession planning. At the time of the assessment, two GPs had joined the partnership, supporting the provider’s capacity to meet future demand.

Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care. Team members highlighted effective communication and stated that they felt included in decision making processes relating to the service.

Leaders were visible and inclusive, and they understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and staff embodied the culture and values of the organisation.

The leadership team worked with other providers in the Primary Care Network (PCN) and were engaged in the development of primary care services within the local area.

Members of the staff team in a range of roles told us that communication across the service was effective.

The provider routinely monitored patient outcome data and implemented improvements where necessary to enhance the quality of care. Overall feedback from service users and stakeholders was positive, reflecting high standards in the care delivered by the practice.

The service fostered a positive culture where people felt they could speak up without fear of detriment and their voice would be heard.

Leaders encouraged staff to raise concerns and promoted the value of doing so. We received 19 completed CQC staff feedback forms and all staff who completed these felt confident to raise concerns.

The provider had established Freedom to Speak up arrangements with another practice in the PCN. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked at the practice.

Policies and procedures promoting diversity and equality were well established. Reasonable adjustments were implemented to support staff in fulfilling their roles and to ensure they felt valued. A flexible approach was adopted, including the provision of part-time working arrangements to accommodate individual needs.

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.

The service demonstrated clearly defined responsibilities, roles, and systems of accountability, underpinned by effective governance. These structures supported the delivery of high quality, sustainable care, treatment, and support. Decisions were informed by robust information on risk, performance, and outcomes, which the service shared securely with relevant parties when appropriate.

Leaders and managers provided effective support to staff, all of whom demonstrated a clear understanding of their individual roles and responsibilities. Regular appraisals and performance reviews were conducted to support professional development. The provider had implemented governance processes appropriate to the scope and nature of the service. Staff had access to all necessary policies and procedures. Managers held meetings with staff, and any resulting actions were clearly communicated and accessible.

The provider used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data and records. Staff consistently demonstrated a strong commitment to patient confidentiality and information security.

There were established arrangements in place for identifying, managing, and mitigating risks. A comprehensive business continuity plan had been developed to ensure service resilience in the event of disruption.

The service demonstrated a clear commitment to collaborative working, recognising its duty to engage with partners to ensure seamless service delivery. The provider worked effectively with external stakeholders, including commissioners, care homes, and partner agencies, to develop and deliver high-quality, coordinated care.

The practice was part of the Kingswinford and Wordsley Primary Care Network (PCN) and offered extended access, and flu and covid vaccination programmes.

The Patient Participation Group (PPG) had recently been re-established with new members. Feedback from three participants indicated a positive outlook, with plans to support the practice in delivering health promotion initiatives, including cancer awareness and hypertension campaigns. The provider actively encouraged wider participation through promotional materials displayed in the waiting area and sign-up forms available on its website.

The service showed a strong commitment to continuous learning and improvement; however, the sharing of learning was not consistently extended to all staff and often depended on the nature of the incident. The provider acknowledged this gap and expressed a clear intention to strengthen the processes for sharing learning more consistently. Regular clinical meetings were held to review patient needs and discuss best practice. A quality improvement plan was in place to support service development, and completed audits evidenced positive outcomes. For example, enhanced monitoring of Non-Alcoholic Fatty Liver Disease and the implementation of personalised asthma plans for patients transitioning between educational settings.

Robust systems were in place to assess the quality of the service and monitor patient outcomes. Where areas for improvement were identified, appropriate actions were taken to enhance service delivery and prevent recurrence. The provider worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.