Shere Surgery/Dispensary

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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 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 a 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 local challenges which affected their service, such as the projected increase in the local population over the coming years and worked with partner agencies to address these challenges, including applying to build an extension to the premises. 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 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. For example, actions plans were not always available, some did not contain timescales for completion of mitigating actions or updated to show progress, and prescription stationary was not being effectively monitored within the practice. Where staff described systems, such as those to ensure staff training was up to date, it had not been identified that these systems were not working effectively. We also noted that identified concerns were not always raised in a timely manner. This meant senior leaders in the service could not demonstrate full oversight of the governance systems and processes. Leaders in the service told us they had recently become aware of some gaps in their systems which they intended to address. Although all staff we spoke with were clear on their individual roles and responsibilities, this did not always ensure that records were kept appropriately.

Leaders proactively supported staff, promoted an open-door policy and regularly met with them to complete appraisals and performance reviews. 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 took confidentiality and information security seriously.

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.