LONGROYDE 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 looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. We saw that there was an established governance and management structure in place, which was regularly reviewed and updated.

Staff showed they were aware of how to raise concerns, and they were confident this would be actioned and issues addressed. Staff who worked at the practice stated they were well supported and received appropriate training and development.

This is the first assessment for this service since its registration with CQC. This key question has been rated as Good.

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 service 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.

Staff told us there was a positive team culture within the practice and they felt supported by GPs and leaders. All staff we spoke with were proud to work for the service and had a vision to deliver high quality patient care.

The practice mission statement was to maintain established services and provide a welcoming service that was caring and accessible for all patients. Staff were aware of this statement and tried to create the best environment for patients.

The leaders were aware of the projected increase in the local population and had seen an increase to their patient base, and was working with partner agencies to address any future challenges.

The service had exceptionally inclusive leaders 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 always did so with integrity, openness and honesty.

It was evident that patients were at the heart of everything the practice did. When looking at Friends and Family data, between January 2025 and May 2025 only 2% of responses came back as negative.

Responses from patients and staff, both to the practice and directly to CQC, were consistently and extremely positive. Staff told us that leaders in the practice were approachable and responded to concerns.

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.

Leaders were aware of the demographic of their workforce, they understood where improvements could be made and planned accordingly.

The service was exceptional at fostering a positive culture where people knew they could speak up and their voice would be heard.

Within the practice there was a Freedom to speak up guardian and they also had established Freedom to Speak up arrangements with another practice manager within the PCN group.

We received staff feedback as part of the inspection process which highlighted there was an ‘open door’ policy.

The practice had a whistleblowing policy in place and the staff knew how to access this policy.

There was also a duty of candour policy in place, staff we spoke to could explain what duty of candour was and were they could find the practice policy. The practice gave us an example of when duty of candour had been used, how the error was rectified and explained to the patient. They also explained the contingencies that had now been put into place to stop any further issues from happening.

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

There was a zero-tolerance policy in relation to the abuse of staff, with mechanisms in place to protect people and minimise the likelihood of recurrence.

All staff were required to complete training on equality and diversity. The practice had a range of policies staff could access that pertained to their safety and wellbeing, such as a lone working policy, bullying and harassment policy, stress at work policy and a staff welfare policy.

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 share 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.

Managers met with staff annually to complete appraisals, and performance reviews were completed during probation periods or if otherwise needed. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures.

The practice had a business continuity plan in place and information to follow in the event of systemic failures. This included action to take in emergency situations such as electrical power failure, environmental issues, inclement weather, and sickness. The business continuity policy contained information on an emergency box readily available at the practice, however we were advised this was no longer in use. The practice advised they usually checked and made changes to any policies annually or if the need arose.

Leaders also had oversight of recruitment, staff sickness and staff turnover and used this information for workforce planning. We saw evidence that the appropriate checks had been carried out for new starters. Staff had completed mandatory training and leaders had good oversight, using a digital platform to check what had been done and what needed doing.

Staff took patient confidentiality and information security seriously. Staff had completed information governance training.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders collaborated with other practices in their Primary Care Network (PCN) to deliver extended access. The practice had multidisciplinary meetings to discuss and improve outcomes of complex patients.

The practice continued to promote continuous improvement by acting on complaints and feedback received.

The practice had an established Patient Participation group (PPG), who met bi- annually. We spoke with members of the PPG, who said they felt the practice valued their opinion and was open and honest with the PPG members.

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

Staff were given allocated time to complete mandatory training.

Information from complaints and significant events were used for learning and improvements.

Quality improvement activity including clinical audit, and these findings were discussed at clinical meetings.