Spital 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 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.

Leaders ensured there was a shared vision, strategy and culture that staff in all areas knew, understood and supported. They demonstrated a positive and compassionate listening culture that focused on learning and development. Staff spoke of a shared vision to provide a high quality, patient centred service that was responsive to people’s needs. Staff described good teamwork and a service that was clear on its function to work in the interests of patients and provide the best patient experience they could.

Regular meetings were held for clinical and non-clinical staff. Members of the team told us that communication was effective, and they felt included in decisions about the service. The culture of the service was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities.

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. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for the service.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. For example, practice meetings were held, and discussions took place about performance and operational pressures. Clinical audit results were discussed in weekly clinical meetings to share learning and agree actions.

All staff we spoke with were clear on their individual roles and responsibilities. Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. The service used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data and records. Staff took patient confidentiality and information security seriously. Staff submitted data and notifications to external agencies as required.

There were arrangements for identifying, managing, and mitigating risks. Health and safety related systems and procedures were in place with a range of regular checks on the environment and on working practices. A major incident plan was in place.

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.