Hill Barton 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 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.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy.

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes. They tailored their care, support and treatment in response to this.

Staff treated people equally and without discrimination.

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.

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 and performance reviews. However, oversight of staff training was not fully embedded as not all staff were up to date with training the service deemed as mandatory. The service was in the process of updating its training policy, to ensure it reflected current recommendations for mandatory training, and they were reviewing training schedules to reflect this.

The service had established governance processes. The service had identified policies and procedures, which staff could access and were requested to provide acknowledgment of having read and understood them. However, oversight of infection prevention and control measures were not consistent, as the service could not evidence the contracted cleaners had laundered fabric curtains in line with IPC guidance. Additionally, environmental cleaning schedules were available in only 1 of 4 clinical rooms. We raised this with the service at the time of our visit, who then provided evidence to show these issues had been actioned. For example, seeking assurance regarding the laundering of curtains, reviewing the use of disposable curtains as an alternative and cleaning schedules now being available in all clinical rooms.

GPs and leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. They clearly recorded any actions that arose from these meetings and shared these with staff.

Staff were aware of the requirement to submit 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.