Fryern 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 Outstanding. At this assessment, the rating remains the same.

This service scored 93 (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 based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the needs of people and the challenges facing their local community. All staff had contributed to the development of the service’s vision and strategy, and leaders regularly monitored progress through partner, leadership and team meetings.

Staff consistently spoke positively about the culture within the service, describing a supportive and collaborative environment where colleagues worked well together and supported one another. They valued the opportunities available for development, regular communication through team meetings and huddles, and the wellbeing initiatives provided by the organisation.

Leaders encouraged open communication and actively sought staff feedback to inform improvements. For example, changes were made to staff facilities following feedback from a staff survey, including the provision of new kitchen facilities. Leaders also recognised local challenges and opportunities, such as increasing demand and future capacity requirements, and were exploring options to expand the premises to support the needs of a growing population.

The service worked collaboratively with partner organisations, including pharmacies, opticians, voluntary sector organisations and the wider primary care network, to improve outcomes for people and support the health needs of the community. Staff development was actively encouraged, with opportunities for progression, additional training and role expansion available across the organisation. Leaders promoted equality and diversity and sought to identify and address any workforce inequalities. They were also aware of future pressures on the service, including projected population growth, and worked proactively with partner agencies to plan for and respond to these 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 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.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service.

Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders maintained oversight of risks through a risk register, health and safety monitoring systems, audits and regular meetings which ensured all safety checks were completed. We reviewed records of governance meetings which demonstrated transparent discussion of risks, performance, service developments and staff feedback, with learning and actions shared across teams.

Leaders used audits, reviews and performance information to drive improvements, including monitoring appointment utilisation, screening uptake and care navigation processes. Succession planning arrangements were in place across both management and leadership roles, including the development and promotion of staff into more senior positions and the ongoing review of future workforce capacity needs.

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, which included verifying people’s identity during remote consultations. 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.