The Village 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

The service had improved and now had clear and effective governance structures in place and comprehensive quality assurance systems. The practice leaders were visible, inclusive, embraced the culture and values of the practice, and had the skills, knowledge, capacity and credibility to lead effectively. There was a focus on staff well-being and development. Leaders were compassionate and took steps to support staff with various needs to carry out their roles well. There was an emphasis on improving the quality of the service and how the practice worked as part of the local health and social care system.

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.

We received staff feedback forms from 11 members of staff. They told us that the atmosphere at work was good overall but could be strained during busy periods. They told us it was friendly and staff worked well together. Ten of the 11 members of staff we received feedback forms from told us that their views were listened to and acted on. Receptionists we spoke with told us that the practice’s mission statement was ‘Committed to Caring’ and this had been discussed with staff at team meetings. They told us they were committed to getting things right.

The aims and objectives of the practice were included in the Statement of Purpose.

Staff we spoke with felt supported by the management team within the practice. They felt there had been significant positive changes since our previous inspections. However they told us the nursing team would benefit from a nurse manager, to direct the team and direct the delivery of services across the two sites. Leaders were aware of the challenges in providing good quality care and had taken action to address them. They told us they needed to promote and support effective team work within the new clinical team to drive forward quality improvements. Access to appointments remained a challenge, as for most GP practices, and a new telephone system had been put in place to support this. Systems had been put in place to provide assessment and oversight of prescribing within the practice. All of the 11 members of staff we received feedback forms from told us they were supported by managers and the GP partners who were visible and approachable. Staff told us there was a clear vision vision within the practice and some of the staff had been involved in creating the vision.

We reviewed minutes of meetings and found that leaders had identified areas of improvement in the delivery of care and treatment and had the skills and experience to identify ways of supporting staff. For example, training on the new telephone system, updates on staff recruitment and support for staff from wellbeing services within Derbyshire. One of the GP partners now worked permanently at the practice and staff we spoke with told us that this meant leaders were now visible and approachable.

Staff we spoke with told us they were aware of who the Freedom To Speak Up Guardian was and how to contact them for support. They were aware of how to whistle blow and where the whistleblowing policy was stored. They told us that leaders were approachable and listened to any concerns they had and acted on them. For example, additional training suggestions. We received staff feedback forms from 11 members of staff who demonstrated they were aware of the whistleblowing policy. Most staff were aware of the role of the Freedom to Speak Up Guardian; those that were not had recently started to work at the practice.

There were policies in place to support staff to speak up if they had any concerns. However, the whistleblowing policy was prescriptive in how staff could raise concerns (in writing) and appeared to discourage staff from raising concerns externally. The policy was amended immediately to remove this sentence. Although the policy referenced the Freedom to Speak Up Guardian, there was no indication of who this person was or their contact details.

Leaders told us they held monthly team meetings. They had used the meetings to support and involve staff, for example, to agree the practice’s mission statement and values. They had also held a well-being session for staff so they were aware of the support available to them and held quizzes and treasure hunts about the service to support different styles of learning.

There were systems in place to ensure that staff completed training in equality, diversity and inclusion. We found no evidence of discrimination in the recruitment of staff.

Leaders could describe their governance arrangements for the practice and told us that leads for each area had been identified. They described the systems in place for monitoring quality outcomes for patients. Receptionists we spoke with were aware of their roles and responsibilities and knew who to approach if they needed support in areas such as safeguarding or infection control and prevention.

There were processes in place to keep staff up to date with changes within the practice. We reviewed the minutes from a staff meeting and found that staff were kept updated of changes within the practice. For example, new staff recruitment, changes to the new telephone system, patient registrations and wellbeing services available to staff working at the practice. There was a suite of policies in place to support the governance within the service. There were processes in place to review and update the policies. A business continuity policy was in place to support the practice to continue to deliver services in the event of an unplanned disaster such as loss of domestic services, a pandemic, service outages, or other potential threats. Whilst the plan had been reviewed on a regular basis by the practice, it still made reference to Primary Care Trusts which are no longer in existence. The practice updated their business continuity plan and removed references to Primary Care Trusts.

The practice worked in partnership with their Patient Participation Group (PPG) to share information with their patients about events and changes within the practice. For example, updates on staffing, the use of pharmacies in managing minor illnesses and the home visiting service provided by the Primary Care Network.

Leaders told us that they continued to work closely with their Patient Participation Group and the home visiting service. Minutes from meetings confirmed this.

The practice worked closely with the Integrated Care Board (ICB) and their clinical pharmacy team. The practice had attended regular progress meetings with both the CQC and the ICB.

There were processes in place to work in partnership with the Patient Participation Group (PPG). We found that regular meetings were held with the PPG to share updates about the practice, to listen to patient views to drive changes within the practice. For example, an analysis of the national GP patient survey results and follow-up patient surveys. The practice worked with the home visiting service provided by the Primary Community Network (PCN). When appropriate, a GP contacted the service to request home visits for patients allowing the GP to remain in the practice to see other patients.

A lead GP told us that they regularly carried out clinical audits to drive improvements within the practice. For example, an audit of the monitoring of gestational diabetes in pregnant women. As a result of this audit a dedicated recall system had been put in place for this group of patients. The lead GP planned to expand the audit system to the wider clinical team. Receptionists we spoke with told us there had been many improvements since our previous inspections. For example, higher staff recruitment and retainment and onsite support from a GP partner which made working within the practice more rewarding and effective.

The practice had engaged in quality improvement work that included a number of single cycle audits. Changes had been implemented although 2nd cycle audit has not been completed to assess if the changes had been effective.