The Fullwell Avenue 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 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, 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.

The practice vision was shared with people who used the service. The service had developed values that would help them achieve this vision. The values included delivering safe, effective, compassionate and high-quality care to meet the medical needs of patients.

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. The service was proud to be a training practice. Staff demonstrated a well-developed understanding of equality and diversity, and how to prioritise safe, high-quality care.

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.

Staff had clear roles, responsibilities, and governance systems to deliver good quality sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Governance processes were mostly well-established, with accessible policies and procedures. However, oversight of recruitment processes and staff training needed strengthening. The practice had a health and safety policy which stated that leaders should provide all employees with health and safety training. At this assessment, managers had decided not to mandate health and safety training to all staff. Managers had not ensured all staff had received sepsis awareness training. The provider took immediate action to review delivery of training and implemented a review of procedures to ensure effective staffing and ongoing compliance.

Leaders used reliable data on risk, performance, and outcomes. Leaders held regular meetings to discuss risk, performance and operational management of the practice.

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. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. We reviewed a sample of minutes from clinical meetings for the previous 3 months. Managers clearly recorded any learning and actions arising from these meetings and ensured they shared these with staff.

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.