Pilch Lane 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 good. At this assessment, the rating remains the same.

This service scored 71 (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.

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.

Staff consistently described a positive, open and supportive culture and described leaders as visible and approachable, and staff felt able to raise ideas and suggestions. Evidence showed staff feedback had resulted in changes to appointment availability. The practice manager described values centred on being caring, approachable and supportive, and these values were reflected in feedback from staff and patients.

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 practice had governance systems to support quality improvement, including regular staff meetings, clinical discussions, significant event reviews and action planning processes. Audits, health and safety assessments and quality monitoring activities were routinely undertaken. Staff knew how to access policies and procedures and described effective communication mechanisms within the practice.

Leaders demonstrated systems for learning from incidents and concerns. Significant events were formally documented, reviewed and supported by an action log to monitor progress and ensure learning was embedded within the service. Staff described an open and supportive culture where suggestions for improvement were encouraged and acted upon. For example, staff told us proposals to increase appointment availability had been discussed during practice meetings and subsequently implemented.

Some governance processes required improvement. Several identified environmental risks, including water temperature monitoring issues, outstanding actions from risk assessments, and concerns relating to the portable cabin needed to be resolved. In addition, records relating to prescription stationery did not provide a comprehensive audit trail. After the inspection the provider sent us an update to confirm that all concerns had been resolved, or action taken to ensure resolution in a timely manner.

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.