Birchwood 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

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. This is the first inspection for this service since its registration with CQC. This key question has been rated as requires improvement.

This service scored 61 (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 clear shared vision, strategy, and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The practice did not always understand the challenges and the needs of people and their communities. The staff we spoke with were able to describe the practice vision and strategy and told us they had been involved in design and implementation. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges, such as cervical screening as this was slightly below average at 76%.

Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff told us they felt they could raise concerns and gain support from the leadership team. The provider encouraged staff feedback in meetings and staff told us they felt supported. Staff surveys were completed regularly, as were staff appraisals. Managers and leaders could account for the actions and behaviours of the staff. Leaders had implemented quality improvement frameworks to address the health inequalities known to the practice, such as the risks of obesity.

The service fostered a positive culture where people felt they could speak up and their voices would be heard. The practice had established Freedom to Speak Up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns and staff did speak positively about the team ethos.

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. Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination, such as the provider being aware of the Equality Act. Adjustments had been made to ensure all staff were valued, for example, we saw adjustments in place to support staff with disabilities.

The service did not always work in collaboration with their external partners. They did not always share information and learning for improvement purposes. At the inspection we found some areas of governance that required strengthening. These included the oversight of clinical tasks, training, the reviews of patient medicines, the delivery of evidenced-based care and staff appraisals. The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. There were areas of good governance, including an effective system for managing medicines and patient safety alerts, patient access for appointments, complaint handling and learning. We found that the practice was caring and responsive.

The service did not always work in collaboration with their partners. They did not always share information and learning with partners and collaborate for improvement, for example, safeguarding concerns. The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. The provider had 1,723 unactioned tasks outstanding for mostly clinical, administration, and practice manager tasks, the oldest being dated December 2024. There were 23 tasks allocated to a clinical pharmacist practice between 10 February and 18 February 2025, who had stopped working at the practice at the beginning of February 2025. We saw there was no updated clinical coding flowchart to show where staff referred clinical pharmacy tasks to until a replacement pharmacist was found.

The service did not always focus on continuous learning, innovation, and improvement across the organisation and local systems. For example, there was a lack of multi-disciplinary meetings with external stakeholders. However, the practice had a quality improvement plan in place.