Bryn Cross 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 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 71 (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. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years and worked with partner agencies to address these challenges. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

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.

The service had clear responsibilities, roles, systems of accountability and good governance but did not always take action to act on risk. For example, prescription logs were not in place to allow the practice to monitor prescriptions that were in stock. The practice did not have a risk assessment in place for any emergency medicines that were not stocked within the practice. After the inspection the practice did complete this and sent it in to us.

The incident reporting policy had not been updated to reflect how the practice was recording significant events. The incidents that were reviewed were found to be lacking in detail. We also found that practice minutes were also lacking in detail and did not always reflect the full discussion during practice meetings. The practice sent us in evidence after the inspection which included an updated significant event reporting policy. The practice did not have a CCTV privacy impact assessment, however this was sent in to us after the inspection.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. Staff could access all required policies and procedures, which were mostly kept up to date and reflected latest guidance. Staff took confidentiality and information security seriously and processes were in place to ensure compliance with GDPR. Staff submitted data and notifications to external agencies as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.