Downton 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 we established governance systems in place and Regular governance meetings were held, risks identified, discussed, managed and mitigated and learning disseminated to improve practice. However, some required strengthening in respect of the management of medicines and record keeping to demonstrate actions had been progressed and risks resolved.

This service scored 71 (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 defined roles and responsibilities and were systems and processes in place to hold staff accountable for these. Staff used data to inform their individual performance and how they met local and national targets to improve patient outcomes.

There were established systems and processes in place to keep people safe. These required strengthening to ensure all risks were identified and reviews of people receiving some medicines were conducted in a timely manner. Where the inspection team highlighted issues these were investigated and acted upon by the service, pausing medication for some patient until reviewed whilst other issues were found to be simple anomalies with the migration of data and coding irregularities. The practice introduced additional safeguards to their clinical systems to highlight these in the future and appraised the clinical team of actions required to take. Regular team meetings were held where risks were discussed, actions allocated to staff and learning disseminated. However, not all were clearly documented to demonstrate when, where and who was present when this occurred or what matters had been progressed and resolved. Despite this, we could see improvements had been made and the services to patients had improved and were safer consequently.

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.