Aire Valley 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

Welookedfor evidence that the service’s leadership,managementand 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 has changed to requires improvement. We found a breach of regulation in relation to good governance and have asked the service for an action plan in response to the concerns identified.

This service scored 62 (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, which was centred on being a trusted and sustainable practice. This aimed to ensure patients received safe, compassionate care, staff were supported to perform at their best, learners had opportunities to develop and grow, and the practice made a positive contribution to the communities it served.

The service had plans to review and update its values during the following year. They planned to involve staff, patients and other stakeholders in shaping the revised values through a range of engagement activities. These would include workshops with staff in different roles, discussions with the Patient Participation Group, and consideration of feedback received through complaints and compliments.

Staff and leaders understood the needs of people and their communities. The service was aware of local challenges which affected the service and worked to address these challenges.

Staff reported a culture of openness and honesty. They told us that leaders and managers were approachable and supportive.

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.

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 demonstrate good governance due to gaps in the effective oversight of processes including staff training, recruitment, infection prevention and control, and premises-related health and safety risk management. Following our feedback, the service had taken steps to address some of these concerns. However, further work was needed to fully resolve all the issues, and to ensure improvements were fully implemented and embedded within the service.

All staff we spoke with were clear on their individual roles and responsibilities. Staff could access all required policies and procedures. Leaders held regular meetings with staff and recorded any actions that arose from these meetings.

Staff took confidentiality and information security seriously. Data security awareness training formed part of the service’s mandatory training requirements.

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.