High Pastures Surgery

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• 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 leadership, management and governance of the service 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 is requires improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they felt the culture of the service was positive, open and healthy. Staff spoke of a shared vision to provide a good quality, patient centred service that was responsive to people’s needs. They described good teamwork and a service that was clear on its function to work in the interests of patients and provide the best patient experience they could.

The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities.

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.

Some of the processes in place to govern the service were not effective. The arrangements for identifying, managing, and mitigating risks required improvements. A range of checks were in place for safe working practices and the environment. However, the provider had not carried out a health and safety risk assessment and actions had not been taken in a timely way in response to issues/risks identified in a fire risk assessment. The provider confirmed that the higher risk elements of this were actioned with immediate effect following our visit and the remainder were scheduled to be addressed.

Staff told us they had undertaken the training they required for their roles and responsibilities. However, the provider did not monitor compliance and we noted gaps in core mandatory training. The processes in place for supporting staff were not formalised. For example, supervision arrangements were not always formalised and documented, not all staff had undergone an appraisal in the past year and staff meetings were not documented and minutes shared.

The provider used data to monitor and improve performance, and they acted on information about risk, performance and outcomes. As part of the established clinical governance processes, a regular suite of searches of the clinical record system were being run to identify patient needs and ensure these were being met.

Staff could access all required policies and procedures. The practice used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data and records. 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.