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

At our inspection in April 2024, we reviewed one quality statement in the Well led key question – Governance, management, and sustainability and found good practice. The provider had systems in place for identifying, managing, and mitigating risks. These were regularly reviewed to ensure they were working as intended. Clinical and internal audit processes had a positive impact on quality governance, and there was clear evidence of actions taken to resolve concerns. There were systems and processes for learning and continuous improvement including a wider shared learning and the involvement of staff at all levels. There were 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 a breach of Regulation 17 Good Governance. The provider was not working to their Prescribing and medication policy. Patient Specific Directions (PSD) were not being adequately managed and prescription stationary was not being tracked in line with NHS guidance. At this assessment we found that processes had been reviewed and changed or improved. We saw evidence that systems and processes were working as intended and was now compliant. There had been a collective approach to ensuring that improvements within the practice were sustainable.

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.

The provider had demonstrated they took these concerns seriously and had made the necessary improvements immediately. The tracking of prescription stationary was changed, and a methodological system was being used. The provider had added a sequence of consecutive numbers to each prescription to ensure ease of tracking prescription stationary. Prescription details were recorded and signed out on a log sheet and when used patient information was also recorded. This was being audited weekly to ensure it was working as intended. We noted that by week 4 the new way of working was embedded. The provider told us they would continue to audit but would move this to monthly. PSDs were no longer in use and instead the nurses were delivering the required vaccinations. This had been reflected in the Prescribing and medication policy.

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.