Aelfgar 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

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Leaders worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

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.

The practice had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Former and long-term current staff had contributed to the development of the practice vision and strategy. Their mission statement was to improve the health, well-being and lives of those they cared for. This was kept under review with the whole team and discussed with new staff during their induction. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff fed back they found leaders and the whole team to be respectful of each other, open and non-defensive. There was accountability, willingness to admit if things hadn’t gone as well as they could and willingness to listen and make changes.

Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with another practice in the primary care network. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider and staff told us they were paid based on their experience and expertise with no gender pay gap. Staff reported their well-being was considered, and leaders regularly ensured workloads were manageable. Staff completed CQC feedback questionnaires, and the findings showed that staff were treated with fairness, dignity and equality and that any concerns were treated in confidence with respect and empathy.

Leaders had authorised numerous flexible working requests for both clinical and non-clinical staff and were responsive to any changes to working as a result of staff disabilities. This was further evidenced when we spoke with staff and received their feedback. Staff reported that they would discuss their working hours with the manager or partner if they needed greater flexibility in their role or needed to change.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example we saw risk assessments and appropriate adjustments were made to support staff in the work place.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Leaders held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. They recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The practice had developed a business development plan which was regularly reviewed for the period 2025 to 2028 which was discussed with the staff team.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. The documentation reviewed showed a lack of a detailed route cause analysis and risk mitigation, although staff spoken with assured us these were fully discussed in their meetings. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

All staff were encouraged to put forward and test out new ways of working. We saw examples of small group training for the nursing team as well as education discussions through clinical meetings and external training support via staff personal development plans. The practice had a quality improvement plan in place to help drive improvements in services.