Swan 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, supported learning and innovation 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, mission statement and culture. This was based on development, quality, professionalism, people and safety. Staff and leaders understood the challenges and the needs of people and their communities.

The Partners met every 6 weeks and met with the department managers every 2 weeks to plan and review business arrangements. Leaders monitored and reviewed progress against the delivery of their business plan. Service leaders demonstrated awareness of the challenges affecting delivery and they worked collaboratively with partner agencies to address these pressures. For example, capacity had been strengthened by employing another Paramedic and virtual care navigation had been implemented, which they planned to develop further as software developed and people became more familiar with the technology.

Leaders actively promoted equality and diversity. They demonstrated a positive and compassionate listening culture that focused on people who used the service and staff. Staff we spoke with gave positive feedback about the service culture.

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.

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. For example, for the safe use of artificial intelligence and the oversight of the completion of actions from environmental risk assessments and audits. 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. Staff belonged to relevant meeting groups where they could add agenda items, record information and track agreed actions. Short, medium and long term actions were monitored and when appropriate, moved to the completed section which provided a clear audit trail and oversight. Staff we spoke with told us these arrangements worked well.

Staff took confidentiality and information security seriously and submitted data and notifications to external agencies as required. The provider was in the process of submitting applications to CQC to change their Registered Manager and update their partnership members.

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.