Elliott Chappell Health Centre Also known as St Andrews 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 assessed 3 quality statements from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was good. Our rating for this key question remains good. The provider had a clear vision and credible strategy to provide high quality, person-centred care. We found the provider had clear and effective governance processes, which supported the safe delivery of care. Staff were clear on their individual responsibilities and knew who was accountable for each aspect of the service. Governance structures and systems were in place and there was evidence of 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.

Staff knew how to raise concerns about the service, and they felt comfortable and empowered to do so. Staff were aware of the Freedom to Speak Up Guardian and where they were located if they needed support

The provider had in place a process for regularly seeking and responding to staff feedback and a whistleblowing policy. However, staff told us that they had never needed to raise concerns using the policy but felt empowered to do so if they wished. We observed the staff notice board that contained key messages and staff updates on a regular basis.

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 and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The services policies were accessible on the computer system and leaders told us that the service reviewed policies annually.

The provider had established governance processes that were appropriate for their service. We saw a sample of the practice polices and saw they were up to date. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. We saw there was a system for recording and acting on patient safety alerts. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

We did not receive any feedback from members of the public regarding this service. The evidence we reviewed did not show any concerns about assessing and reviewing their health care needs. The provider had arrangements in place to allow patients the opportunity to provide feedback on the service received. The patient participation group (PPG) had been dormant for some time since the Covid19 pandemic however, we were told by the provider they were seeking an alternative source to form a PPG centrally within the PCN.

Leaders described and evidenced how they collaborated with a range of relevant stakeholders and agencies. For example, regular engagement with the GP practices who used the service, the Integrated Care Board and Healthwatch. We found staff and leaders were open and transparent.

We did not receive any feedback from partners and the ICB regarding this service. The evidence we reviewed did not show any concerns about assessing and reviewing their health care needs.

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.