The Chesser Surgery

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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 assessed 5 quality statements from this key question. Our rating for this key question is requires improvement. We found that the service was not providing well led services. This is because staff told us they had raised concerns with leaders, however the provider could not demonstrate there was an effective freedom to speak up protocol in place. We also found that governance processes in place had not ensured that safe and effective care were being provided.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders detailed a clear vision and values for the service. This was shared with staff who told us they had input into the direction of the service. Staff were aware of and understood the vision, values and strategy and their role in achieving them.

We found that there was a clear vision and set of values, which the service acted on. The service had a realistic strategy and supporting business plans to achieve priorities. The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population. The provider monitored progress against delivery of the strategy.

Staff told us that leaders were generally visible and approachable. Leaders told us that they worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

Notwithstanding this, a number of staff had raised allegations about the behaviours of one of the leaders at the service. Staff told us that the work behaviours of the individual had not been appropriate.

There were clear lines of responsibility to support capable and inclusive leadership. The practice had put in place job descriptions for all staff and had ensured staff were aware of their roles and responsibilities.

Leaders at the service had made decisions that were not risk assessed and were potentially unsafe. We were told that a clinical room was being used for a purpose it was not intended for and the provider had not completed a full risk assessment in response to this.

Leaders at the service told us that the organisation considered it important that the voice of staff could be heard. A number of staff had raised concerns about the alleged behaviours of one of the leaders at the service, and staff described inappropriate behaviour going back a number of years. While leaders at the practice had managed issues informally with the individual on a number of occasions, it was reported that poor behaviours were normalised and were not actively managed.

There was a freedom to speak up policy in place at the service. However, the service had not reviewed its freedom to speak up processes in response to an allegation of bullying and harassment by a colleague over a number of years. There was also a delay in the appropriate action being taken in response to the allegations raised.

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 were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control. Leaders detailed and demonstrated that they had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

The governance processes in place at the service had not ensured that safe and effective care were being provided. The inspection found concerns relating to staffing, infection control, medicines management and leadership in the practice.

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.

Leaders explained there was a process of continuous learning, improvement and innovation in the practice. They explained that audits formed a key part of practice learning as it led to change. Complaints and significant events were reviewed, and learning shared within the practice and externally.

There was a focus on continuous learning and improvement at all levels within the service. Staff knew about improvement methods and had the skills to use them. Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.