Mortimer 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

The service had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities. Governance systems were in place to identify and manage risks however some area required strengthening.

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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years and worked with partner agencies to address these challenges.

The staff wellbeing strategy was embedded across the practice, promoting staff wellbeing through a structured programme focused on psychological safety, and employee voice. Staff we spoke to indicated that flexible working arrangements were supported, including the option to work from home where appropriate.

Staff we spoke to described leaders as approachable and felt their ideas were listened to and considered.

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 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.

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 held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service.

During the inspection, we found concerns regarding the secure management of prescription stationary. In response, the provider promptly developed and implemented a protocol to ensure secure storage, access control and regular monitoring.

The provider had an in house dispensary. The leaders had established policies, procedures including Standard Operating Procedures (SOPs) for dispensary staff to follow.

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.