The Acorn & Gaumont House 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 rated inspection, this key question was rated inadequate. At this assessment the provider demonstrated that improvements have been made. We assessed 7 quality statements from this key question. We found that the service was providing well led services in most areas. The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients. There were clear responsibilities, roles and systems of accountability to support good governance and management. The service involved patients, the public, staff and external partners to support high-quality sustainable services. However, the provider had not implemented a suitably robust risk management process.

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 detailed clear vision and values for the service. This was shared with staff who told us they had input into the direction of the service. Staff told us that they felt engaged by leaders. They told us that they were listened to, and detailed examples of how they had contributed to the development of the service. Staff were aware of and understood the vision, values and strategy and their role in achieving them.

There was a clear vision and set of values, which we saw that the service acted on. The service had a realistic strategy and supporting business plans to achieve priorities. The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population. The provider monitored progress against delivery of the strategy.

Staff told us that leaders at all levels were visible and approachable. They told us that they worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

There were clear lines of responsibility to support capable and inclusive leadership. The practice had put in place job descriptions for all staff and had ensured staff were aware of their roles and responsibilities.

Leaders at the service told us that the organisation considered it important that the voice of staff could be heard. Staff told us they understood how to raise concerns and were confident that the leadership of the organisation would act on them.

There was freedom to speak up policy in place at the service. There were formal mechanisms by which feedback from all staff groups could be shared with the managers of the service.

Leaders told us that the service actively 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.

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.

Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control. Leaders detailed and demonstrated that they had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

In response to the previous inspection the leaders had developed a new governance structure that provided oversight by the practice partners. Action plans and performance were re viewed at meetings. However, the provider had not implemented a suitably robust risk management process. The service did not utilise a risk register and were not able to demonstrate a process my which risks were identified, monitored and mitigated. The service could therefore not be assured that all risks had been identified and mitigated.

We received no specific feedback in this area.

Leaders told us they collaborated with stakeholders and had active Integrated Care Meetings engaging with district nursing, care agencies, mental health, care navigators and palliative care. The service also had a social prescriber to whom patients could be referred. They told us that a full and diverse range of patients', staff and external partners' views and concerns were encouraged, heard and acted on to shape services and culture.

The service was involved in a large number of meetings with other healthcare providers in the local area to develop the way care was delivered. This included developing systems such that patients would not need to call 111 or attend urgent treatment centres.

Leaders explained there was a process of continuous learning, improvement and innovation in the practice. They explained that audit was to form a key part of practice learning as it led to change. Complaints and significant events were reviewed, and learning shared within the practice and externally.

There was a focus on continuous learning and improvement at all levels within the service. Staff knew about improvement methods and had the skills to use them. Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.