Whiteparish 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 71 (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.

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 the strategy and demonstrated an awareness of local challenges that could affect the service, including the projected increase in the local population over the coming years.

The service had developed a values and behaviours statement which clearly set out the culture, behaviours and standards expected of staff. The statement promoted compassion, kindness, professionalism, teamwork, continuous learning, respect and inclusion, and reflected the service's commitment to delivering high-quality, person-centred care. Leaders promoted a positive and supportive working environment where staff were encouraged to communicate openly, work collaboratively and contribute to service improvement. This helped to create a shared understanding of the service’s values and objectives and supported a positive culture across the organisation.

The service promoted a positive and compassionate culture that focused on listening, learning and development. Records of meeting minutes and actions were stored electronically and were accessible to all staff. Service leaders also produced monthly newsletters which shared learning, policy updates and information relevant to the team, including updates from stakeholders such as the Integrated Care Board (ICB) and local care homes. This helped ensure staff remained informed and engaged with developments affecting the service and the wider health and care system.

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 did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems and processes were not always effective in identifying, monitoring and managing risk. Although the service had systems in place to monitor areas such as staff training, policies, human resources, premises management and equipment maintenance, these had not consistently provided leaders with full oversight. We identified gaps in governance arrangements relating to health and safety, fire safety, infection prevention and control, staff training, clinical supervision and auditing processes. Existing monitoring systems had not always identified where actions remained outstanding, records were incomplete, or where oversight of externally delivered services required strengthening.

During the assessment, service leaders demonstrated a willingness to respond to identified concerns and took action to strengthen governance arrangements. This included reviewing monitoring processes, updating recording systems, introducing additional policies and audit tools, and strengthening oversight of staff training, clinical supervision and external contractors. Leaders also advised that they would review access arrangements for key records and documentation to ensure information remained accessible when required and to support effective operational oversight. However, some actions were recent, and their effectiveness had not yet been fully embedded or demonstrated.

Despite these concerns, the service had established governance processes which supported many aspects of service delivery. Staff were clear about their roles and responsibilities and were able to access up-to-date policies and procedures. Leaders held regular meetings to discuss risks, performance and opportunities for improvement, with actions recorded and shared appropriately. The service demonstrated a proactive approach to learning and improvement, including reviewing business continuity arrangements following a planned power outage and updating contingency measures as a result. The service also used audits, quality improvement activity and performance monitoring to review outcomes and support improvement.

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.