South Saxon 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

We looked for evidence that the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and 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 positive culture. This was based on transparency, equity, equality, inclusion and respect for human rights. Staff and leaders understood the needs and challenges of people and their communities.

The service took proactive steps to promote equality, embrace diversity and address any workforce inequalities. Staff told us the working environment was flexible to meet individual needs and supportive regarding individual health conditions. They described a supportive environment where they enjoyed going to work.

The service’s mission statement was displayed in the waiting area demonstrating the standards and values they aim to provide to people who use the service. This had a focus to deliver the highest quality primary care in a safe, supportive and compassionate environment.

Staff found leaders to be approachable and supportive, and leaders spoke well of their team.

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 did not have fully effective systems of good governance. They did not always act on the best information about risk.
The service did not always have evidence in place to provide assurance regarding governance oversight. These included gaps in recruitment documentation, IPC management, and the documentation of environment and equipment cleaning. Additionally, the service did not have good oversight of staff training compliance meaning staff were not up to date in several areas of statutory and mandatory training. The service had some risks assessments in place however they did not have a service risk register to proactively identify, monitor and mitigate all risks.
However, the service had clear responsibilities, roles and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support.
Staff had access to required policies and procedures, which were kept up to date and reflected latest guidance. Leaders proactively supported staff and regularly met with them to complete appraisals.
Leaders held regular meetings to discuss service delivery and to identify opportunities for service improvements. Any actions that arose from these meetings were shared with staff including learning from best practice guidance, safety alerts, incidents and complaints.
Staff took confidentiality and information security seriously. Staff submitted data and notifications to external agencies as required. Complaints were taken seriously and detailed investigations and responses were provided; learning was shared in meetings.
Following our assessment, the service demonstrated that all areas of shortfall had been addressed and new governance processes have been introduced to support ongoing compliance. The service has shared evidence of updated staff records and staff training, service and equipment cleaning, newly implemented risk assessments and evidence demonstrating the implementation of a comprehensive risk register, which provides oversight of identified risks.
 

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.