Nethergreen 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 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.

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, 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.

Leaders monitored and reviewed progress against the delivery of their strategy, holding bi-annual away days to discuss priorities, including skill mix and contingency planning. The service demonstrated awareness of local challenges affecting delivery. Although formal equality and diversity training had not been recorded, staff demonstrated a good understanding of these principles and a positive, compassionate listening culture, with a clear focus on learning and development.

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 roles, responsibilities, and systems of accountability, supported by generally effective governance arrangements. These were used to manage and deliver high-quality, sustainable care, treatment, and support. Leaders acted on the best available information regarding risk, performance, and outcomes, and shared this securely where appropriate.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service with opportunities identified to further strengthen oversight of staff training and induction processes. Effective systems were in place to monitor safety alerts, incidents, and complaints. 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. Leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously, which included verifying people’s identity during remote consultations. Staff submitted data and notifications to external agencies as required.

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.