The Carriage House Clinic

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

Effective leadership and governance were in place to assure systems were operated effectively and risks were identified and mitigated. There was a supportive culture among the staff group.

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, objective and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people who accessed the service.

All staff including healthcare assistants and administration staff were involved in meetings and communication regarding the running of the service. The provider had considered which areas of clinical care it could effectively expand its services. When doing so there was consideration of safety, governance processes, resources and guidance which would be required prior to delivering new services.

The provider had inclusive leaders at all levels who 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.

The service was led by GPs and a manager. Staff described the leaders as approachable, visible and responsive.

The service had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns and were confident to do so if needed.

The service valued diversity in their workforce. They work towards an inclusive and fair culture or by improving equality and equity for people who work for them.

Policies and procedures which promoted diversity and equality were in place.

The service had delegated responsibilities, roles and systems of accountability. These roles were supported with extensive and detailed governance processes such as audits, standard operating procedures, policies and systems to manage risks. Staff had access to policies and procedures. Regular governance meetings took place.

The audits used to monitor care identified improvements and assured quality and safety.

Staff engaged with the sector, peers and partners to share learning. They used these networks to identify new or innovative ideas that can lead to better outcomes for people.

The service had a collaborative approach and keen focus on continuous learning and quality improvement. Quality improvement audits and peer reviews were used to identify and drive areas for improvement and enable proactive changes. For example, a testosterone prescribing audit identified 33 patients receiving a prescription and 29 had been monitored in line with guidance and where patients were not, no prescribing took place in the periods of time where monitoring tests were overdue. Clinical record audits took place and staff were provided with feedback including any areas for improvement.