During an assessment of Surgery
We carried out this assessment on 28 and 29 January 2025.
We carried out this assessment as a responsive inspection, due to concerns we had about the service. We assessed 5 key questions: safe, effective, caring, responsive and well led. We rated surgery services as good overall because:
Safe:
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. There were mostly enough staff with the right skills, qualifications, and experience. Managers made sure staff received training and there were improvements in the number of staff receiving regular appraisals to maintain high-quality care.
However, process did not ensure all equipment was maintained and safe to use. Medicine management did not support patients to manage their own medicines.
Effective:
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services, such as at discharge. Staff made sure people understood their care and treatment to enable them to give informed consent.
Caring:
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. Staff mostly responded to people in a timely way. The service supported staff wellbeing.
Responsive:
People were involved in decisions about their care. The service provided information people could understand. The service worked to eliminate discrimination, reduce health and care inequalities and ensure the service was easy to access for all.
However, people experienced delays to their treatment. Cancellation of surgery on the day of surgery was not uncommon and although waiting times had improved, some patients were still waiting over 52 weeks for care and treatment from the time of referral to the service.
Well-led:
A lack of auditing and oversight information for some areas of the service meant staff did not always have the best information to act and improve risks, performance, and outcomes.
However, leaders and staff had a shared vision and culture based on listening, learning and trust. Most leaders were visible, knowledgeable, and supportive. Staff were treated equally, and staff with protected characteristics felt supported. Staff understood their roles and responsibilities. There was a culture and structure for continuous improvement being embedded into the service.
The service was previously in breach of the legal regulation in relation to safe care and treatment (assessment of venous thromboembolism risk) and good governance (secure storage of patient records). At this assessment we found the service had made improvements in relation to these 2 specific areas of these regulations. However, we found they were in breach of different areas of good governance (assessment and monitoring of the service).