Maidstone Road Rainham 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 equity, equality and human rights, diversity and inclusion, engagement, and understanding 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. The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

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 did not always have clear responsibilities and systems of accountability. They did not always act on the best information about risk.

Governance systems were not always operating effectively to ensure risks to people using the service were identified and mitigated. For example, systems to identify and act on fire safety risks were not fully embedded. In addition, arrangements to manage the risk of legionella were not effective. Whilst annual water testing was undertaken, the service had not completed a legionella risk assessment and did not monitor water temperatures in line with its own policy.

The service’s Legionella policy outlined the primary method of controlling the risk of Legionella was through the monitoring of water temperatures. It also stated that a Legionella risk assessment was important to identify potential risks and inform appropriate control measures, with water sampling used as an additional control. These measures were not consistently implemented.

Systems to support safe recruitment practices were not consistently followed as recruitment files not always complete.

Following assessment, the service acted on the feedback provided and took action to address these concerns. Including, reviewing fire safety processes, scheduling a Legionella risk assessment and reviewing staff records.

However, we saw leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all required policies and procedures. Managers held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took 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.