Islip 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

The service had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Leaders accounted for the actions, behaviours and performance of staff through clear and effective governance processes. Areas of improvement were identified around the oversight of mandatory training and prescription stationery processes. The practice responded positively, taking prompt action to address concerns and strengthen its systems.

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 provider had a shared vision, strategy and culture that was embedded across the practice. The practice’s vision statement and mission were clearly displayed in staff rooms ensuring the staff were aware and aligned with organisations values and objectives. Leaders monitored and reviewed progress against the delivery of their strategy.

The practice was aware of local challenges which affected their service and local population, such as the projected increase in the elderly population over the coming years. The practice was working proactively to address these challenges by planning and adapting services to meet the changing needs of the local population.

Staff and leaders demonstrated a positive and supportive learning culture. Staff we spoke to told us they felt encouraged to develop their skills and were supported by leaders within the service. They described the culture as open and inclusive, and said they felt valued in their roles.

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 practice did not always have systems of accountability or good governance.Staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals. However, during the onsite visit we identified concerns regarding the management and oversight of prescription stationery and identified gaps in mandatory training records.

Following the onsite visit the practice provided evidence of a prescription stationery register and standard operating procedure (SOP) for secure management of prescription stationery demonstrating appropriate arrangements were now in place.

We also identified areas of improvements in the dispensary. The practice responded promptly and proactively, taking immediate action to address the issues. The provider was responsive and demonstrated a willingness to learn from these findings and strengthen governance arrangements. Evidence was provided that the provider was taking action to address issues related to mandatory training and embed the process for secure management of prescription stationery.

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.

The practice benefited from long standing and experienced staff who provided continuity and strong knowledge of patient population over the years. The leaders told us succession planning was considered to support sustainability of the service.

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.