Brereton 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 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 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.

The service had a clear vision statement, which staff were aware of even though they had not been involved in the development of. The vision statement was discussed and reviewed during practice meetings. The vision statement was to improve the health, well-being and lives of those we care for. The vision statement was underpinned by the mission statement and the aims and objectives.

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 was working with partner agencies to understand the potential impact. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development. Leaders described the culture of the service as supportive and caring. This was reflective of the discussions we held with staff. Staff told us they felt supported to raise any concerns both professionally and personally which they knew would be listened to and acted on. Staff told us they enjoyed working at the service and staff were supportive of each other.

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. Leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff submitted data and notifications to external agencies as required.

The service carried out a range of audits to help drive improvements. The service routinely audited capacity and demand and patient feedback and used this information on an ongoing basis to ensure sufficient appointments and appropriate staffing levels. The service monitored compliance with policies and procedures, for example: daily fridge temperatures, prescription tracking and completion of cleaning schedules.

A member of the nurse team had been supported to develop a quality improvement project through ‘Nurses in Bloom’. The project focused on targeting people with diabetes who did not attend for an annual review and had carried out reviews on 8 out of the 9 regular non-attendees. Staff shared examples of the positive impact of the review for individual people.

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.