Willaston 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

The practice had a culture which drove high quality sustainable care. There were clear responsibilities, roles, and systems of accountability to support good governance and management. There were clear and effective processes for managing risks, issues and performance. However, the clinical searches conducted during our assessment identified some lack of oversight with medicines management processes. Action was being taken to address this and minimise risks. There was evidence of effective systems and processes for learning and continuous improvement.

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.

Staff told us there were clear responsibilities, roles and systems of accountability to support good governance and management. They understood their role and responsibilities including lead roles, such as safeguarding. Managers could account for the actions, behaviours and performance of staff. Staff told us that managers and leaders were visible and approachable, and said they could provide feedback and had opportunities to raise concerns or suggest new ideas to leaders. We saw how information about risk, performance and outcomes, was shared and how change was discussed and implemented following feedback from both staff and patients.

There were comprehensive assurance systems which were regularly reviewed and improved. This included those for managing risks for patients and staff such as learning from significant events. However, the clinical searches conducted during our assessment identified some lack of oversight with medicines management processes. The provider was aware of this and had already taken action to address this including having planned audits and recruitment of a medicines manager to lead the oversight arrangements. The process for using clinical audits had a positive impact on quality, and there was evidence of an audit programme for continuous improvement. The provider was open and transparent and completed a series of actions to ensure concerns highlighted during this assessment were promptly addressed. There was a process to support and manage staff when their performance was poor or variable. The practice used digital services and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management.

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.