Dr Telesilla Gueret Wardle Also known as The Christchurch Hall 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 practice’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, we focused on 2 quality statements relating to the key question Well-led: Shared direction and culture and Governance, management and sustainability.

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 practice 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.

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 practice and the Primary Care Network were aware of local challenges which affected the service and worked with partner agencies to address them. It had a range of governance protocols setting out how care and support was provided to patients from marginalised groups.

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 feedback we received from 11 staff members supported this, describing the culture as excellent, well-organised and supportive. They said the working environment was friendly, communications were good and staff morale was excellent. We saw that staff turnover was low. It was apparent that staff worked together to provide a patient-centred and caring service. Staff felt able to raise concerns with leaders and there was an identified Freedom to Speak up Guardian.

The practice had an active Patient Participation Group (PPG), with 6 core members, which met every 4 months. We saw examples of suggestions by the PPG being acted on, for instance information relating to meningitis had been posted in the waiting area following the Kent student cases earlier in the year.

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 practice had clear responsibilities, roles, systems of accountability and good governance. It used these to manage and deliver good quality, sustainable care, treatment and support. It acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We received feedback confirming staff members were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews.

The practice had put in place a suite of governance policies in relation to the quality statements we reviewed during this assessment. The practice sent us a wide range of the policies which we saw were regularly reviewed, according to a set schedule, updated to reflect latest guidance and shared with all staff. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously. We saw evidence of staff receiving governance training relevant to the roles and responsibilities, such as information governance and the UK General Data Protection Regulation. 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.