Almondsbury Surgery Also known as Hanham Health

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 clear shared vision, strategy, and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion, and engagement. Staff and leaders demonstrated an exceptional understanding of the challenges and the needs of people and their communities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

The service used its clinical software search tool monthly to monitor performance, supporting informed decision-making and helping to identify areas for improvement. For example, the service routinely monitored and reviewed people on specific medicines, this enabled the service to monitor activity and take necessary action where required. This demonstrated a consistent and shared approach focused on improving outcomes, contributing to a positive culture of delivering high-quality care.

The service was aware of the needs of their local population and had appointed a palliative care lead, as well as a newly recruited cardiovascular (CVD) specialist. This demonstrated a shared direction and strong organisational culture focused on improving outcomes for people using the service, proactive workforce planning, and meeting the specific health needs of the community, including supporting local care homes.

The patient participation group told us leaders in the service were approachable and responded to any concerns raised. They also told us leaders modelled the values of the service. We saw the leadership team worked exceptionally well across both of their sites and were fully engaged in the development of primary care services within the local area.

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. They used these to manage and deliver high-quality, sustainable care, treatment, and support. They always acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

Leaders demonstrated excellent oversight of governance arrangements. This included having systems and processes for monitoring maintenance checks, staff training, recruitment, and general risk management. All documents relating to maintenance and risk were readily available and up to date.

The service maintained a comprehensive 6-year record of all safety alerts. Records demonstrated alerts were consistently reviewed and monitored, with clear documentation of actions taken, changes implemented, and information shared with relevant staff.

Leaders and managers supported staff, and there were clear structure charts. Managers had regular management meetings to ensure they maintained delivery of high-quality care. We reviewed minutes from these meetings demonstrating risks and performance were discussed and planned for.

Managers met with staff regularly to complete appraisals and performance reviews. We reviewed samples of these records and noted all staff consistently had annual appraisals. In addition, all GPs had regular mentoring sessions with clinical supervisors.

There was a comprehensive programme of clinical audits with clear oversight to monitor and track audit cycles, results, and outcomes. These were monitored effectively and repeated in a timely manner and the results were shared with the relevant members of staff for ongoing shared learning and improvement. The provider submitted evidence of33clinical and non-clinical audits, which they had carried out to improve outcomes for people. These covered medicines,medicine monitoring, and monitoring of long-term conditions. Leaders and staff told us audits were discussed at clinical and staff meetings; this was confirmed in the minutes of the meetings we reviewed, which showed the findings were shared and learning outcomes, changes to clinical practice or policies and procedures were cascaded to staff.

The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Staff took confidentiality and information security seriously.

There was a range of meetings with staff, during which they discussed clinical, non-clinical concerns and emerging risks. This included general practice meetings, GP meetings, clinical staff meetings, reception meetings, and managers meetings. We saw evidence of minutes being circulated in the event of a missed meeting.

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.