Horndean 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 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 Good.

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 and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

All staff participated in creating the service’s vision and strategy, which was regularly reviewed. They told us they valued being included in this process and having the opportunity to contribute. The service was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service. We saw the leadership team worked with other GP services in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had set up Freedom to Speak Up systems, including a designated staff member and an external contact at the local integrated care board (ICB). Staff knew how to raise concerns if necessary.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example should staff need assistive technology or modified equipment the service provided this.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The service had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular meetings with staff, during which they discussed clinical concerns, emerging risks and shared learning. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took people confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Care homes supported by the service described strong working relationships and valued the continuity provided by having named GPs. The provider worked with other GP services within their primary care network to offer Basic Life Support staff training. PPG members said the service listened to them and they felt heard when feedback is given

The service focused on continuous learning, innovation and improvement across the organisation and local system. The service had a learning culture and discussed and shared learning from significant events with staff. Leaders undertook annual full review of all complaints and incidents. This allowed for further analysis of trends and identified further learning. The service also had a service improvement plan and routinely reviewed the effectiveness and appropriateness of the care provided. For example, upon recognising its local population had a high proportion of home-schooled children, the service had implemented a home-schooled children log. This was to ensure such children were receiving all relevant immunisations, typically offered by the school nursing team whilst children are in school settings.