Wonersh 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 reviewed one quality statement in the Well led key question – Governance, management, and sustainability. We found a breach of Regulation 17 Good Governance. The provider was not working to their Prescribing and medication policy. Prescription stationary was not being tracked in line with NHS guidance. There was no policy for staff to follow for Patient Specific Directions (PSD). The PSD’s we reviewed did not contain sufficient information for the staff member providing the vaccination and there was no record of the vaccine given added to the patient record. The scores for the other quality statements are based on the previous rating for this key question. The provider had systems in place for identifying, managing, and mitigating risks. These were regularly reviewed to ensure they were working as intended. Practice leaders had established policies, procedures and activities which were reviewed and updated as required. Staff were clear on their roles and accountabilities. There were comprehensive and successful leadership strategies in place to ensure and sustain delivery and to develop the desired culture. Leaders had a deep understanding of issues, challenges, and priorities in their service, and beyond. However, we found that prescription stationary was not adequately tracked through out the practice and there was no policy for staff to follow for Patient Specific Directions. Following our inspection, the provider demonstrated they took immediate action in response to our findings. However, as this had only recently been implemented, we have yet to evidence that this has been embedded and working as intended.

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.

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.

We found a breach of Regulation 17 Good Governance. This was due to the provider not working to their Prescribing and medication policy. Prescription stationary was not tracked in line with NHS guidance. There was no policy for staff to follow for Patient Specific Directions (PSD). The PSD’s we reviewed did not contain sufficient information for staff members providing the vaccination and there was no record of the vaccine given added to the patient record. This meant the provider was not maintaining an accurate, complete, and contemporaneous record. Following our inspection, the provider demonstrated they took immediate action. They sent us evidence to provide assurances that they took these concerns seriously and were making the necessary improvements. These had only recently been implemented so there is not yet verified evidence to show they were working. Leaders were aware of the work and improvements required to maintain and improve the level of care and treatment to patients. The provider held regular staff meetings. Including weekly partner meeting, 3 monthly practice meetings, and informal coffee meetings for all clinicians. Practice meetings had a standing agenda which included significant events, safeguarding, complaints, and any action plans. We saw evidence of a wider shared learning and the involvement of staff at all levels. The provider had a strategic development group who made decisions to support the practice for any future developments and had succession plan in place. We also saw evidence of the tracking of mandatory staff training, risk assessments, and there was an up-to-date business continuity plan in place. There were comprehensive assurance systems which were regularly reviewed and improved. Clinical and internal audit processes had a positive impact on quality governance, with clear evidence of actions taken to resolve concerns. There were evidence of systems and processes for learning and continuous improvement.

Staff we interviewed had a clear understanding of their roles and responsibilities and that of others. They were aware of where to find guidance when needed. They were encouraged to speak up and where needed discussed openly concerns and were involved where possible in finding solutions. Staff were aware of the process to raise significant events and encouraged to do so. There were 38 staff members employed to work at the practice. We spoke with 10 staff members and received 13 staff CQC questionnaires. Staff members told us there was a friendly and supportive environment to work in. Managers and GPs were approachable, and staff felt supported by the whole team. Staff we spoke with commented positively on the opportunities to learn and develop, and that ideas and suggestions were welcomed. We heard of examples where suggestions had been acted upon. Staff told us that changes within the practice were communicated either by the email, meetings, or word of mouth. The practice manager reviewed patient feedback from the friends and family test, and this was circulated to all staff via the ‘Friday feedback’ email.

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.