Falkland House 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 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. The service was aware of challenges which may affect their service, such as recruitment and contingency planning. Staff and leaders actively promoted equality and diversity. They demonstrated a positive and compassionate listening culture that focused on learning and development. All staff we spoke with told us they felt very supported by both the GP partners and the practice manager and felt able to raise concerns and suggestions for improvement. Staff reported feeling listened to and described the team as supportive and cohesive. They spoke highly of management and the support provided and consistently described a positive and happy working culture.

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, although some appraisals were slightly overdue, these were scheduled in. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service. 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 demonstrated awareness of confidentiality and information security. During the visit, two network access cards were observed left unattended in locked computers. This was discussed with the provider, who was advised to address the issue. 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.