Brewood 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 lacked governance in some areas identified during the assessment. We found there were management and accountability arrangements in place, however, these were not always effective. Staff could explain their roles and understood their responsibilities. The provider had systems in place to manage performance which could be further improved to ensure staff competency was formalised and documented.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between all members of staff which focused on learning and improvement. Staff told us leaders were visible, approachable, were valued and listened to. Staff enjoyed their work despite the workforce challenges within the last 12 months. New staff told us there were unaware of the practice vision and values, we fed this back to the provider for actioning.

The practice had a strategy in place and had signed up to a number of improvement initiatives within their PCN and with stakeholders. There were processes such as regular meetings to inform their strategy and best practice. There were policies readily available such as whistleblowing and safeguarding. Leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between all members of staff which focused on learning and improvement. Staff told us leaders were visible, approachable, were valued and listened to. Staff enjoyed their work despite the workforce challenges within the last 12 months.

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.

Staff told us there were clear governance arrangements in place. Staff we spoke with were clear about their roles and responsibilities and that of others.

There were policies, processes, and systems in place to support governance and management, but these were not always effective. Shortfalls included the management and oversight of risk in some areas. For example, the issues we identified at the Coven site, staff training and recruitment processes , emergency medicines and cervical screening uptake. There was a workforce plan in place and a named Caldicott guardian. There were systems for information governance .

The practice had an active PPG and had consulted the group before making changes to services. For example, before introducing a new telephone system, the PPG told us they felt valued and included in the development of the practice.

Staff and leaders told us they had developed good practice and collaborated with all relevant external stakeholders and agencies. Staff reported the practice liaised and worked in partnership with community healthcare professionals. Staff told us they worked closely with a local care home and had developed a good working relationship.

NHS Staffordshire and Stoke on Trent ICB were aware of the information of concern shared to the CQC. The practice of its own volition had engaged NHS England's Supporting General Practice Team for independent support and guidance.

The practice had systems in place to collaborate with third parties and stakeholders. For example, palliative care nurses and district nurses. The practice had liaised with external agencies including the ICB, supporting general practice team and NHS England's complaints team to improve shared learning.

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.