Elm Hayes 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 Good. At this assessment, the rating remains the same. The service had made improvements and is no longer in breach of legal regulation in relation to governance.

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.

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.

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 now 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 share this securely with others when appropriate.

Since our last assessment, the service had improved its management of clinical supervision by introducing a clearer system to hold and record supervision sessions and keep evidence of discussions. The service also improved oversight of infection prevention and control through risk assessments, closer monitoring of external cleaning, 3-monthly cleaning audits, and regular deep cleaning of carpets. The provider now had establishedgovernanceprocessesin relation to the quality statements we reviewed during this assessment, which wereappropriatefortheir service.

Leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews, as well as clinical supervision discussions. Staff could accessallrequiredpoliciesandprocedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed clinical concerns and emerging risks, including in relation to infection prevention and control matters. Leaders clearly recorded any actions arising from these meetings and ensured they shared these with staff.

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.