Albany House 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 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 provider had a clear vision and values which focused on providing personalised, compassionate care and maintaining continuity for patients wherever possible. Staff understood the needs of the local population and described how they adapted services to meet those needs.

Staff and leaders spoke positively about the culture within the practice. They described leaders as visible, approachable and supportive, and told us they felt comfortable raising concerns or sharing ideas. Staff said there was an open and honest culture, and that leaders listened to feedback and involved them in changes and improvements.

The provider supported staff development through training, supervision and protected learning time. Staff told us they felt valued and supported in their roles and spoke positively about the opportunities available to develop their skills and take on new responsibilities. Leaders had also supported staff wellbeing, including making reasonable adjustments and providing additional support when needed.

The provider understood the challenges facing the practice, including access to appointments, staffing pressures and limitations associated with working from a Grade II listed building. Leaders worked with local partners and organisations to identify solutions and improve services for patients. Staff consistently described the practice as having a supportive and inclusive culture, where both patients and staff were treated with kindness and respect.

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 provider had clear responsibilities, roles and systems of accountability to support the delivery of safe and sustainable care. Leaders used information about risk, performance and outcomes to monitor services and identify opportunities for improvement.

Staff understood their roles and responsibilities and told us they felt supported by leaders. The provider held regular clinical, operational and practice meetings where risks, performance, audits and service improvements were discussed. Actions arising from meetings, audits and risk reviews were recorded and monitored to ensure progress was made.

The provider had established governance processes to support the delivery of care. Leaders used audits, clinical searches, action plans and risk registers to monitor quality and drive improvement. For example, the provider had implemented clear treatment guidance and role-specific processes to promote consistency in people's care. This helped ensure people received the same standard of treatment regardless of which doctor they saw and reduced the risk of variation in outcomes.

Staff could access policies and procedures relevant to their roles, and these were reviewed and updated to reflect current guidance. The provider had systems in place to manage information securely, share information appropriately with partner organisations and submit data and notifications to external agencies when required.

The provider recognised current and future challenges, including workforce pressures and increasing demand for services, and had plans in place to support the ongoing delivery of care.

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.