Grayshott 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 service leadership, management and governance 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 Requires improvement due to breaches in regulation relating to good governance. At this assessment, the rating has changed and is now rated Good.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us leaders in the practice were approachable and responded to any concerns raised.

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.

Since our last assessment, the service had proactively reviewed their governance systems and updated them to ensure they were working effectively. The provider had now established governance processes that were appropriate for their service. The service had recently made changes to their management team which staff and leaders described as positive. The service had clear responsibilities, roles, systems of accountability and good governance. Legionella and fire risk assessments had been undertaken by external providers. The service had developed action plans based on the external assessment and we saw evidence that these were regularly monitored and that leaders in the service were aware of the mitigations required as well as progress towards completion. Leaders in the service had oversight and had made decisions which prioritised the most urgent actions. Leaders acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. 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. We found that some policies, such as the duty of candour policy did not reflect the practices that were described as being followed, and some did not include all relevant information, including the business continuity policy. The provider told us that they would review and update these polices at once and would also review their other policies to ensure they were accurate and up to date.

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.