Abbots Bromley Surgery

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• 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 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. All staff we spoke with demonstrated a clear understanding of this vision, which emphasised accessibility and a personalised approach to care. Staff also reported that they had a good understanding of their practice population, supported by the size and location of the practice.
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 with staff informing us leaders were keen to see staff develop within their roles. The practice also gathered feedback from staff in form of anonymous questionnaires. The results from this were mostly positive.
 

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 mostly good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They mostly 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 met with them to complete appraisals.

The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were mostly appropriate for their service. Although risk assessments and audits had been completed, there was no overarching risk log in place. Following the assessment, the provider subsequently shared the risk log they had developed.
Staff told us they attended meetings within the practice, during which they discussed emerging risks and potential improvements to the service. Staff also told us these meetings were recorded and shared with staff.

At the time of our assessment, the practice’s CQC registration was not up to date. This included the need to add one partner, remove a registered manager, and updated the statement of purpose. Although the practice had initiated the process to add a partner, an administrative issue meant this remained ongoing at the time of both the assessment and the drafting of this report. The practice had also begun updating its statement of purpose once this was brought to their attention.
 

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.