Ashfield Road 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 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 service had a clear mission statement which was displayed within the premises and on the service website. Staff understood the service’s values and were able to demonstrate how their roles, responsibilities and approach to work supported the delivery of care in line with these values.

Leaders provided evidence of meetings, projects and discussions that demonstrated a commitment to promoting a positive culture within the service. Staff feedback also included examples of how this positive culture had helped maintain good service delivery during challenging periods. Staff described effective teamwork, supportive leadership and an environment where open and honest discussion was encouraged.

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 lines of responsibility and accountability. Governance systems were in place; however, these were not always effective in identifying, assessing and managing risks.

Staff we spoke with understood their roles and responsibilities. Leaders met regularly with staff to provide support, guidance and supervision, including annual appraisals. Staff told us they felt supported and were able to raise concerns when needed.

The provider had governance processes in place, but these did not always identify risks or ensure appropriate mitigating actions had been implemented. Staff could access the policies and procedures they needed, and these were regularly reviewed and updated. Leaders held regular staff meetings where concerns, service developments and learning opportunities could be discussed. However, we found that changes to some processes, such as the completion of Disclosure and Barring Service (DBS) checks, had not been supported by a documented risk assessment. This meant the provider could not fully demonstrate how potential risks had been identified and managed.

There was a clear and well-developed workforce plan to support consistent and continuous service delivery. This included staff who were trained to work across a range of roles and could provide support at short notice when required. Leaders also had development plans in place to support workforce sustainability and future service needs.

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.