Branch End 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 provider’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 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 provider had a very clear shared vision, mission and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders demonstrated an exceptional understanding of the challenges and the needs of people and their communities.

All staff contributed to the development of the provider 's mission and vision, which were kept under regular review. The Patient Participation Group was also consulted during the initial drafting process to ensure a joined-up approach to working.

Leaders monitored and reviewed progress against the delivery of their strategy. The provider was aware of the local challenges affecting delivery, including limitations associated with the current premises and the ongoing difficulties presented by its rural location. These factors could impact patients' access to additional services, and the provider took them into account when planning and delivering care.

Staff and leaders actively promoted equality, diversity and inclusion and worked to identify and address the causes of any workforce inequalities. The Equality and Diversity Policy had recently been reviewed and redrafted to strengthen its alignment with the practice, improve accessibility and understanding for staff, and demonstrate leaders' commitment to embedding these principles in everyday practice. As part of this commitment, leaders signed up to the NHS Sexual Safety Charter and completed a self-assessment to evaluate their performance as a provider and identify opportunities for further improvement.

Leaders demonstrated a positive and compassionate listening culture that promoted learning, reflection and continuous development. Staff spoke highly of the culture within the practice, describing a supportive team environment and strong leadership. Learning opportunities were actively encouraged for all staff, and the practice's role as a teaching practice further demonstrated its commitment to education and workforce development. Staff described the culture as open and transparent and felt confident that any concerns raised would be listened to, acted upon and used as opportunities for learning and improvement.

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 provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver 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.

The provider had established governance processes for most of the quality statements reviewed during this assessment. However, arrangements for monitoring staff immunisations required further strengthening to provide effective oversight and assurance of compliance. Leaders responded promptly to the findings of the assessment, taking immediate action to address identified gaps and to improve future monitoring arrangements.

Leaders actively supported staff and met with them regularly to complete appraisals and performance reviews. There was a strong emphasis on staff wellbeing, with reasonable adjustments and other supportive measures implemented where required to help staff perform their roles effectively. Staff told us they felt valued and respected by leaders, who had an open-door policy and were responsive and available to provide guidance and assistance when needed.

Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the practice. Leaders clearly recorded any actions that arose from these meetings and shared these with staff.

Managers regularly reviewed significant events and complaints to identify themes, trends and opportunities for learning. Learning from these reviews was shared with staff to support practice development. Staff also undertook an annual review of complaints and significant events to identify any recurring themes and areas where changes could be made. The findings were discussed at staff meetings to promote reflection, shared learning and continuous improvement.

Staff took confidentiality and information security seriously.

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.