Valley View 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

Concerns were raised with us around leaders’ actions and lack of a positive, compassionate, inclusive culture that promoted trust and understanding. Staff told us they felt confident to raise concerns about patient care, however not all staff felt they could speak up about other issues without fear of retribution. There were concerns that ongoing disputes, resulting in limited interaction and communication between some staff, could eventually impact patient safety. There was no business plan in place detailing risks, objectives and how these objectives would be achieved. The practice understood their duty to collaborate and work in partnership with other services, to support communities. Staff told us they were provided with adequate training for their roles and supported with their professional development.

This key question has been rated as Requires Improvement. We have identified a breach of regulation 17 (good governance) and have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Evidence collected during the assessment did not demonstrate that leaders had a shared vision, direction and culture. The practice told us its vision was ‘to work in partnership with our patients and staff to provide the best primary care services possible working within local and national governance, guidance and regulations’. Staff told us they had not been involved in the planning of the practice’s vision and values.

The practice had set out some actions and plans for the year, however there was no formal robust business plan in place detailing risks, objectives and how these objectives would be achieved.

Concerns were raised with us around leader’s actions and lack of a positive, compassionate, inclusive culture that promoted trust and understanding.

Leaders told us they had an open-door policy to ensure staff had appropriate support when required, however there was mixed feedback from staff which informed us that this was not always the case.

Staff told us they had been supported to undertake training and development, and that they had the opportunity to attend regular meetings where information was shared with them.

The practice had a whistleblowing policy and Freedom to Speak up arrangements, and staff were aware of how to raise concerns. Staff told us they felt confident to raise any concerns about patient care and felt these concerns would be acted upon. However, evidence from our assessment did not demonstrate that all staff felt they could speak up about other issues without fear of retribution.

There were systems and processes in place to support the safety of staff. This included policies on lone working and zero tolerance. Equality and diversity training was part of the mandatory training for staff.There was also a reasonable adjustments policy in place for staff, and we heard examples of how staff had been supported to carry out their role, for example by being able to work flexibly when this had been requested.

The practice did not always have clear responsibilities, roles, systems of accountability or good governance.

Evidence collected during the assessment did not demonstrate that leaders had a shared vision, direction and culture. Concerns were raised by staff from and about colleagues at different levels of the practice regarding a negative culture and lack of kindness, respect and support. There had been reports of verbal altercations between colleagues, and feedback we received raised concerns about the impact this was starting to have on other staff. At the time of the assessment, we did not see evidence of any direct impact of these issues on patient care. However, there were concerns that ongoing disputes, resulting in limited interaction and communication between some staff, could eventually impact patient safety.

Staff we spoke with were clear about their role and responsibilities. Although we saw some evidence of communication to staff, of changes in staff roles and responsibilities, some staff told us they were not clear about the role of some of their colleagues and were not always informed of changes to colleagues’ roles.

There was a meeting structure in place and minutes were made available to staff. Staff attended regular meetings where complaints, significant events and clinical concerns were discussed. Policies were in place and accessible to staff.

Workflows for correspondence and pathology results were up to date at the time of our assessment. There was however a backlog of 481 patient records to be summarised; after the assessment the practice told us it had reduced this to 139 records.

There were processes in place to maintain safe and effective staffing at the practice, however clinical supervision processes for non-medical prescribers were limited.

We reviewed data for the NHS Friends and Family Test (FFT) for March to June 2025 and saw there were 5 or fewer responses each month. Results for the yearly National GP Patient Survey had been consistently poorer than local and national averages. However, the practice had not carried out its own surveys in an attempt to improve participation, obtain a better view of its patient population, and thereby take appropriate action to improve patient experience. They told us this was something they were considering.

Leaders told us they were aware of the practice’s consistently low performance in cervical screening and childhood immunisation uptake and were continually working on ways to improve this. However, our most recent data from March 2024 showed that uptake rates for 4 of the 5 childhood immunisation indicators had decreased since March 2023.

At the time of the assessment there was no formal robust business plan in place detailing any risks, objectives, and how these objectives would be achieved. After the assessment the practice produced a brief business plan which listed its key objectives and actions.

The practice told us it was aware of the need to submit data and notifications to external organisations as required.

There was a business continuity plan and this detailed arrangements in place in the event of certain incidents.

There was a data security protection policy in place and information governance training was provided to staff. Staff we spoke with were aware of the importance of patient confidentiality and information security.

The practice understood their duty to collaborate and work in partnership, so services worked efficiently for patients. They told us about the ways in which they supported communities, for example by participating in community events and holding regular coffee mornings at the practice.

The practice worked closely with the primary care network and local practices and services. For example, we heard that staff had supported other practices with the transition to cloud-based telephone systems.

The practise gathered patient feedback from the National GP Patient Survey, Friends and Family Test (FFT), complaints and compliments. We reviewed the responses to the NHS Friends and Family Test (FFT) for April to June 2025 and found that at least 60% of respondents rated their overall experience of the practice as good or very good each month. However, there were 5 or fewer responses for each month.

There were no in-house patient surveys. The practice told us it planned to start sending out regular patient surveys to gather more feedback.

Staff told us they were provided with adequate training for their roles and some staff gave examples of how they were supported with their professional development.

The practice used clinical audit to monitor and drive improvement. It also participated in the Lowering Antimicrobial Prescribing (LAMP) and Campaign to Help Improve Respiratory Prescribing (CHIRP) audits. The practice had recently decided to take part in the National General Practice Improvement Programme, in order to drive improvement within the practice.