Werrington 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

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.

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. The practice’s mission statement was to promote, encourage and support excellence and this was visible to staff and patients throughout the practice. The practice had a 5-year plan, including an intent to grow their own staff, including 2 staff completing their prescribing training and one staff member training to become a pharmacy technician. The surgery was a training practice and hosted both medical students and research students and encourage doctors who have trained within the practice to come back to work within the surgery once qualified. There was an open culture and clear learning within the practice. Staff who responded to the staff feedback questionnaire said that leaders were visible and approachable, however some did not always feel supported in their role.

We found systems to ensure compliance with the requirements of the duty of candour and processes in place for communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian outside of the practice. We found that 90% of staff had completed an annual update of equality and diversity training. There was a clear vision and set of values, which we saw that the service acted on. The provider planned the service to meet the needs of the local population.

Leaders 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. Leaders told us they had an open-door policy, and that staff received annual appraisals. All staff who responded to the staff feedback questionnaire said the leadership were approachable, however some did not always feel confident that leaders responded to all concerns raised. Most staff reported a positive working environment, however, some staff reported that during the past year staffing levels had attributed to some staff feeling at times under pressure.

There was a business continuity plan in place. Records showed that most staff had received an annual appraisal. There were policies for complaints and evidence this was being discussed or that lessons learned were being shared with the team. The practice worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

Staff reported there was an open culture within the practice, and they felt able to raise concerns. All staff who responded to the staff feedback questionnaire said that they knew what whistleblowing was, however 25% of staff said they were not sure if the practice had a freedom to speak up guardian and how to contact them.

There were processes to support staff in line with a named freedom to speak up guardian outside of the practice in line with best practice.

Leaders told us that the service promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff told us that they felt equality and diversity was respected by leaders and the service.

Policies and procedures to promote diversity and equality were in place. Staff had received equality and diversity training. Leaders provided an environment free from discrimination and harassment, where staffs contribution was valued, and they were protected from abuse.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings 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 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 information about risk, performance and outcomes, and shared this securely with others when appropriate.

We spoke to members of the patient participation group (PPG) who told us they met with the practice every 3 months and were provided with updates. The PPG was currently being rebuilt after a loss of members over the Covid period. The surgery had a strong relationship with the community run library next door, who run a number of health and wellbeing activities, including breastfeeding support, walking football and general activities to combat loneliness.

Leaders told us they worked with stakeholders and the local community. The practice was part of Moorlands Rural Primary Care Network (PCN) which provided enhanced services to patients. The PCN met regularly to deliver services to meet patients’ needs and to support care provision and service development. Leaders told us they had a patient participation group (PPG), and meetings were held every 3 months.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. As part of the primary care network the practice was supported by a Clinical Pharmacist, Pharmacy Technician, Care Coordinator, Health and Wellbeing Coach, Social Prescriber and First Contact Physiotherapist.

The provider worked with other practices within their primary care network to offer extended access. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

Staff told us that the service focused on continuous learning and improvement across the organisation and local system. All staff had completed a programme of training which was reviewed by leaders to ensure training was monitored and kept up to date.

The practice had a quality improvement plan in place to help drive improvements in services. This focussed on the appointment system and a new triage system had recently been introduced. There were regular practice meetings being held with staff with standing agenda items to review learning. We saw evidence to demonstrate that the outcomes from significant events or complaints, were shared with staff to promote learning and mitigate future risks.