Statham Grove 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 practice had a mission statement which was to provide safe, effective, caring, responsive and well-led NHS primary medical care for their registered population. This would be achieved by treating patients with dignity, listening to what matters to them, involving patients in decisions and supporting them to live healthier, more independent lives. The mission statement was displayed throughout the premises. The practice vision was shared with people who used the service. The service had developed values that would help them achieve this vision.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development. The service was proud to be a training practice. Staff demonstrated a well-developed understanding of equality and diversity, and how to prioritise safe, high-quality care.

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.

Staff had clear roles, responsibilities, and governance systems to support high-quality, sustainable care. Leaders used reliable data on risk, performance, and outcomes. Staff were well-supported, understood their roles, and received regular appraisals. Governance processes were mostly well-established, with accessible policies and procedures. However, oversight of recruitment processes and safety risks in the practice environment needed strengthening. During the assessment we observed emergency equipment was only subject to monthly checks and the cold chain policy for logging of daily temperatures of the vaccine fridges was not always followed. The practice manager told us they had responded to these findings and made improvements.

Staff demonstrated a commitment to confidentiality and information security. Leaders used reliable data on risk, performance, and outcomes. Leaders held regular meetings to discuss clinical concerns, performance and operational management of the practice and recorded and shared actions clearly. Following our feedback, the provider took immediate action to review safety risk assessments and implemented a risk register to ensure effective monitoring of risks and ongoing compliance with safety standards.

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.

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.