Pembroke 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection in March 2016, we rated this key question as Good. At this inspection, the rating remains the same and continues to be rated Good.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The leadership team had a comprehensive understanding about the changes in primary care, with a view to improve patient care and access, and invested in new ways of providing primary care. This included closer work with the other practices within the Primary Care Network (PCN).

Verbal and written feedback from staff demonstrated leaders in the practice were approachable, responded to any concerns raised and were dedicated to making changes to improve the practice. For example, the practice structure had been reviewed, and a new role of operations manager created a role to provide additional support to the management team, admin team and patients.

Staff also told us leaders modelled the values of the practice.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. There were internal arrangements for staff to raise concerns and the practice had established external Freedom to Speak up arrangements with another practice in the primary care network (PCN) to support staff. Verbal and written staff feedback highlighted they were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

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.

Over the last 5 years, the practice had experienced changes as to how the service was managed and governed. At the time of this inspection, the management team had clear responsibilities, roles and systems of accountability to support good governance. From the evidence collected at this inspection, it was clear the management team delivered 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. Staff feedback highlighted managers supported staff at the practice. All staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Following a successful technology migration, staff told us and demonstrated how they accessed all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Actions arising from these meetings were clearly recorded and shared with staff. All staff took patient confidentiality and information security seriously.

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.