Dudley Wood 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

At the last inspection we found the practice did not have fully embedded governance system, there was a lack of leadership and oversight, the culture did not always effectively support high quality sustainable care and there was no evidence of systems and processes for learning, continuous improvement and innovation. At this inspection, we found that the provider had taken action to address areas of governance, management and accountability and there were now safe systems in place to manage performance to ensure staff had the skills and knowledge so people had safe care and treatment. We found that there was leadership in place to ensure there was adequate oversight and there were systems in place to manage risk, issues and performance. The practice had designated roles for areas of accountability. There was succession plans in place, supported by a business plan. The practice leadership were aware that they had further work to do to embed and monitor new processes to assure themselves of maintaining this improvement.

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.

There were systems to ensure compliance with the requirements of the duty of candour and processes in place for effective communication and shared learning. There was a whistleblowing policy in place and a named freedom to speak up guardian. All staff had completed mandatory training which included equality and diversity. The practice had a mission statement in place “To deliver high quality and effective health care to all of our patients, tailored and responsive to the needs of the local population. We aim to treat our patients with dignity and respect”. The practice had a realistic strategy and were reviewing their supporting business plans to achieve sustainability. This included the recruitment and retention of staff and the continued engagement with the community and stakeholders.

At the last inspection we found that the practice culture did not always effectively support high quality sustainable care. However, during this inspection staff told us that there had been improvements in the culture and communication and staff now felt supported by the leadership team and felt able to raise concerns without fear of retribution. There was an open culture and clear learning within the practice. Regular meetings were held with staff and the management team encouraged the reporting of incidents to identify ways in which the practice could continually improve.

The management team had reviewed their roles to ensure areas of accountability within the practice. There were plans in place for the development of staff as part of their succession planning. At the time of our inspection new infrastructures was being developed. For example. A new IT system had been implemented and a new telephone system was in the process of being planned to improve patient access. The practice were working in line with the general practice improvement model to ensure that resources were in place and that the practice remains sustainable and plans and delivers improvements.

At the last inspection, staff described the practice team as supportive, however we found at times the management was not always visible. Leaders understood the challenges to quality and sustainability and had reviewed their business plans to ensure there was capable and effective leadership. The practice had the appropriate oversight and supervision to ensure staff were carrying out their role’s effectively. We were told that permanent recruitment remained a challenging, however there were processes in place to ensure long locum arrangements were in place to support the practice and mitigate risk. Lead roles for accountability had been reviewed further and the leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue. As part of the practice’s mandatory training we saw evidence that all staff had completed equality and diversity training.

Staff told us there had been improvements in the culture since the last inspection and they were confident in raising concerns and felt supported. There were regular meetings held with staff and there was a freedom to speak up guardian in place. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve. All staff had undertaken equality and diversity training.

We were told that there was an emphasis on the safety and well-being of staff and they had put plans in place to recruit additional staff further to increase capacity and resources. Staff told us they had completed equality and diversity training and they were treated fairly and there was an open door policy.

There were policies and procedures in place for the safe recruitment of staff which had been reviewed further since our last inspection. Other policies included recruitment, selection management and processes, equality and diversity, bullying and harassment, grievances and the race equality policy. All staff had completed equality and diversity training and had access to regular appraisals, one to ones, coaching and mentoring, clinical supervision and revalidation. There was an induction process in place for newly appointed staff which outlined the practice’s aims which is “to create a supportive learning environment to enable you to reach your full potential and that there will always be someone available to support you and you should always feel able to ask for advice”.

Staff told us that practice policies were accessible and they were clear about their roles and responsibilities . All newly appointed staff had completed an induction and had opportunities through training and development to improve their job skills and felt supported by the management and clinical team. We were told that there was regular management meetings to review sustainability and ensure there was enough staff in place. There were contingency plans and arrangements in place to recruit locum staff for the needs of the service. Information was discussed and cascaded to staff in practice meetings to share learning,

At the last inspection the provider failed to undertake effective quality and risk monitoring and we found some of the systems in place to support good governance were ineffective. However, during this assessment we found that a new IT system had been implemented to support governance structures and systems and processes had been strengthened to provide safe and effective care. There were recovery plans in place to manage backlogs of activity and delays to treatment. There were clear systems in place to monitor, review and implement changes where these were necessary. Complaints, significant events and safeguarding processes were clearly understood, and all staff knew who to go to in the event there was a concern being raised. We found the appropriate meetings were taking place to ensure governance processes worked and quality was being delivered. A business continuity plan was in place which gave guidance to staff for the preparation of major incidents. We found that policies contained clear information about the designated lead in areas such as infection, prevention and control and safeguarding. All staff were aware of the designated leads in these areas. The practice had policies in place for sharing information with third parties, for example primary care network (PCN) staff.

There were processes in place for partnership and community engagement. For example, regular meetings were held across the primary care network to deliver joined up care and to Sharing good practice and learning. In addition, the practice held regular practice and clinical meetings to collaborate effectively and make improvements in patients care and treatment.

Leaders told us they worked with stakeholders and the local community. The practice was part of a 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. At the last inspection there was no regular meetings being held with staff, however this had been reviewed and there was evidence that regular meetings were held to share learning, continuous improvements and to deliver services to meet patient’s needs. Leaders told us they had a patient participation group (PPG) and meetings were held every 3 months. There were 6 active members and we saw evidence that the last PPG meeting was held virtually in March 2024. The practice had engaged with the PPG on areas of improvement in the last 12 months such as friends and family test, patient survey feedback and to support them in their prostate cancer campaign.

The lead GP told us that there had been increases in demand and they were working with the primary care network and stakeholders to ensure that resources were planned and continued collaboration and partnership working were in place to meet the needs of the service.

At the last inspection we found improvements were needed for learning. Staff told us that sine the last inspection improvements had been made and there were now regular practice meetings held to share learning and to review quality improvement activity to drive improvements. All newly appointed staff had completed a programme of induction and training which was reviewed by leaders to ensure training was monitored and kept up to date.

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. We found that the practice had carried out a number of targeted quality audits and used information about care and treatment to make improvements.