Whittington Moor 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

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care. Leaders implemented quality frameworks to improve equity in experience and outcomes for people using services and tackle known inequalities.

This service scored 96 (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.

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.

Leaders told us they held an annual planning meeting to agree a practice development plan, succession planning and review staffing levels to promote sustainability. Staff told us they discussed complaints, significant events and also death reviews and audits were highlighted to clinical staff to facilitate shared learning. There was evidence of meetings held between managers/partners and the practice team to discuss key issues affecting the staff and team, to share information, and provide an opportunity for staff to raise any concerns. Minutes of PPG meetings held with the practice demonstrating a commitment to engage with patient representatives and seek their views in shaping services to ensure patients views are heard. Partners worked collaboratively with other practices through their primary care network and local medical committee. A wellbeing champion had been nominated to support staff internally with team building events held regularly to foster team working. However their governance systems had failed to identify some of the risks we found during our assessment. For example, lack of risk assessments for the recommended emergency medicines kept at the practice, appropriate authorisations to administer medicines and clinical supervision for non-medical prescribers. Most areas of concern highlighted during the inspection were immediately remediated.

There was a vision statement to guide staff to see how their roles support the future strategy for the practice. We saw a business plan with key objectives for the year; it identified leads for multiple areas and included business plans for the monitoring of medicines used in the treatment of rheumatoid arthritis and chronic disease care, osteoporosis, Quality and Outcomes Framework, staff training, safeguarding and prescribing. There was a comprehensive overarching risk assessment system in place to monitor risks to the service. For example, fire, legionella, Disclosure and Barring Service checks, immunisations, premises. We found that there were several risks missing from the spreadsheet including risk assessments for recommended emergency medicines, and a trailing electrical wire around a sink. The risk register was updated to reflect these. An audit programme was in place to monitor performance and promote quality improvement. There was a suite of polices to support governance throughout the practice. A data security and protection toolkit policy set out the practice framework for maintaining and enhancing high-quality data such as complete, accurate, appropriate, accessible and timely data in all forms. A freedom to speak up/whistleblowing policy was in place. There was a named freedom to speak up guardian at another practice. There was a Duty of Candour Policy in place. Significant events and complaints were reported, recorded, and reviewed every 6 months to look at trends and themes. Learning was shared with the practice team and changes were made to make improvements after an event has occurred.

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.