Merchiston 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 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 the same.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The service now fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had recently appointed an internal Freedom to Speak Up Guardian and had arrangements with another GP service in the local primary care network for staff to contact if needed. Contact details for the appointed Freedom to Speak Up Guardians were now available on the dedicated staff noticeboard, within the service’s whistleblowing policy, and included in mandatory e‑learning training to support staff awareness. The noticeboard also displayed key contacts and signposting information, alongside the current whistleblowing policy, helping to increase visibility and understanding of how staff could raise concerns.

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 now 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders supported staff effectively and now had appropriate systems and processes in place to ensure training, supervision and oversight were well-maintained. Clinical governance had also been strengthened since our last assessment through improved documentation and the implementation of more structured supervision arrangements. The leadership team had embedded processes for monitoring mandatory training and professional development, with compliance routinely monitored and discussed at senior meetings. Staff were supported to access training opportunities relevant to their roles.

The service had worked with the nursing team to continue developing their skills, including areas such as IPC. Leaders met with staff regularly to complete appraisals and performance reviews, and staff had access to all required policies and procedures through the provider’s established governance systems.

Leaders also now held regular meetings with staff, during which they discussed clinical concerns and emerging risks, with clear actions recorded and shared. Leaders had begun introducing standing agenda items to strengthen communication and oversight during staff meetings. In addition, the service had appointed a personal assistant to support leaders in ensuring complaints and internal processes were being followed.

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.