High Street 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. At this assessment, the rating is now good.

Staff understood their roles and responsibilities and the service now had effective, embedded governance systems for managing people’s clinical correspondence, and the security of prescription stationery. Improvements had been made to the effectiveness of medicines reviews and the appropriate prescribing of gabapentinoids.

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 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.

Policies and procedures were now in place and were sufficiently detailed to ensure safety and safe systems of care. This included for example, the management of coding and hospital discharge letters. Staff we spoke with told us they could access all required policies and procedures.

Staff we spoke with were clear on their roles, for example for the safe management of prescription stationery. We reviewed arrangements on site and found this had improved, with documented checks in place to provide assurance that established procedures and arrangements were being consistently followed and embedded.

Leaders had reviewed their roles, capacity and governance processes. Leaders and managers supported staff, and staff we spoke with were positive about the support they received. Managers held regular staff and clinical and governance meetings during which they shared updates and discussed clinical issues and emerging risks. Actions arising from these meetings were documented and available to staff.

The service had an annual audit schedule which was overseen by the service leaders. This included for example, audits to check the quality and effectiveness of medicine reviews and to make sure discharge letters were updated by the pharmacy team and relevant review was in place by clinicians. Learning identified from audits was shared with the relevant staff teams and at the Clinical Governance meeting to support learning across the service. Assurance systems were embedded sufficiently to enable service leaders to identify and act on issues identified from audits.

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.