ACES (Cromwell Road)

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• 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 rated well-led as good. We assessed 1 quality statement on governance, management, and sustainability. There was a clear system of governance and risk management based around delivering safe and good quality care and treatment. The department was prepared for emergencies and major incidents and worked with others as part of a multiagency response. However, we found some areas of improvement in governance of processes of medicines management in the service.

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 had time and resources to undertake effective governance and manage risk. There was a good range of accurate and timely data and information available to understand performance and quality and improvements were made as needed. Governance was used to learn, improve and innovate. Information held about patients was secure and protected. Staff were part of the emergency preparedness network, and they had the strategies and guidance to respond to major incidents. Staff attended staff meetings where leaders shared audit results, health and safety information, information governance, amongst other timely topics. According to results from the staff survey in April 2024, staff shared that team meetings kept them up to date with information, policies, procedures, training, and competencies. Staff also shared they felt the service had a positive impact on patients. Surgeons met regularly to cover a wide range of topics regarding the service delivery, including safety, quality, sustainability, service development and governance.

There were regular and effective meetings led by a consultant and nurse who were leads for safety, audit, quality, and governance. These meetings addressed and gave tine for discussion on key areas of performance, risk, audit, culture, and workforce. Minutes showed areas of concern were identified and actions were taken to learn and improve. Changes had been made when needed to improve the service. Good practice was recognised and celebrated. There was effective workforce planning including for managing major incidents or emergencies. However, we found areas for improvement in governance of medicines management in the service. While there were medicines audits and medicines policies in place, we found inconsistencies in ensuring processes were completed in line with the policies.

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.