Holmcroft 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

This is the first inspection for this service since its registration with CQC 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. Staff reported the culture had changed and improved in the last few months. They found the support of the interim service manager on site had made a difference. Structures to support governance and mitigate risks were in place and a suite of policies developed to support this. This key question has been rated as good.

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. 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 Trust had a vision and values statement, quality priorities and for their values, compassionate, approachable, responsible and excellent. The Trust strategy developed for 2023-2028 set out their ambitions for the local population health. Staff at Holmcroft Surgery were aware of the Trusts vision and values. The interim service manager had plans to work with new staff and the staff team to underpin the service values. Staff reported the culture had changed and improved in the last few months. They spoke positively of the change and found the support of the interim service manager on site had made a difference. Non-clinical and clinical staff felt able to approach any member of clinical staff for support and guidance. Staff told us that leaders understood the challenges within the practice and had taken action to address them. Staff were working with managers to further develop their understanding of their responsibilities to these for the practice.

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.

Staff told us leaders were approachable and responded to any concerns raised. Eight practice staff surveys were received by Care Quality Commission. These reported positively on approachable leaders, however, more localised focused meetings were suggested as a potential for improvement. 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 service had a Freedom to Speak Up guardian and champions in place with policies to support staff, as well as a whistleblowing policy. The service provided supervision, staff meetings, manager meetings and discussion on patient access each weekday. There had been 2 staff wellbeing sessions held, and the service had set up an informal staff ‘niggles’ board, which was taken to practice meetings for resolution/discussion. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They worked 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. The Trust maintained a Diversity and Inclusion statement. Staff told us they felt supported with their individual health needs. Adjustments had been made to ensure all staff were valued. For example, we saw adjustments to support staff were in place.

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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff to complete appraisals and performance reviews. Staff spoken with told us there had been positive change in relation to listening and actioning their feedback. The Trust had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Practice meetings were held with staff, during which they discussed clinical concerns and emerging risks. Managers recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously. The service had developed an action plan and risk register which was regularly reviewed, monitored and discussed. Information included staff, patient, and stakeholder suggestions/feedback and in house findings for improvements. These were risk rated. The organisational structure for the Trusts primary care directorate included practice lead roles for example, safeguarding, Caldecott Guardian, autism and learning disability and information governance.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The Trust worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. We contacted stakeholders for feedback in respect of the service. A stakeholder reported they were engaged in respect of any concerns and queries arising with Holmcroft and the Trust primary care directorate leadership team. We spoke with care homes that the practice supported and received a varied response. However, they reported leaders had actioned their concerns. A patient group who had reported negatively on the service were invited to participate and engage with the local team to co-produce action plans in attempts to resolve matters arising. This developed into a patient working group. The leadership team reported positively on the effectiveness of these engagement meetings and the development of a mutual understanding of the service they provide and of the patient's perspective.

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.

Holmcroft Surgery are an accredited training practice; the doctors are usually training to become GPs and will spend anywhere from 4 to 12 months at the surgery. They have usually worked for 2 to 3 years in a variety of hospital specialities prior to joining the surgery. The surgery had a quality improvement plan in place to help drive improvements in services. Healthwatch, with agreed amendments to the questionnaire had commenced a Healthwatch survey at Holmcroft Surgery to encourage further patient engagement and feedback. All staff were encouraged to put forward and test out new ways of working.