Forest House 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

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers and leaders could account for the actions, behaviours and performance of staff. The systems to manage current and future performance and risks to the quality of the service enabled a proportionate approach to managing risk that allowed new and innovative ideas to be tested within the service. There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care. However, during the assessment we found policies that had not been reviewed for several years, the provider was responsive and reviewed these documents during the assessment phase. The areas we covered during our assessment were governance and assurance.

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.

Leaders told us about governance, management and accountability arrangements, staff understood their roles and responsibilities and managers could account for actions and performance of their staff. Leaders were aware of known risk within the practice and had weekly meetings to address concerns or governance issues. We found clinical systems to be well managed which allowed for effective supervision, effective management of patients and data used to improve patient care.

There were governance structures and systems which were regularly reviewed. There were effective arrangements for identifying, managing, and mitigating risks. A major incident plan was in place. The practice had systems and protocols in place to ensure data and notifications were submitted to external organisations as required. There was evidence of quality assurance activity and clinical auditing, and this was used to make improvements. We found policies were not always reviewed and kept up to date with relevant information, however staff were acting and aware of up-to-date information, the practice leaders took immediate action to review and amend outstanding 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.