Woodstock Bower 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

The service had a shared vision, strategy and culture. We found there was strong, highly regarded leadership within the practice. Staff reported very strongly of being valued, and the family feeling of the practice. They described acts of compassion. This was highly valued by staff and reflective of the approach taken in the practice more generally. Such feedback was replicated by patients. The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service strongly valued diversity and had built an inclusive, fair culture that promoted equality and equity for staff. The provider had governance systems and processes that were largely effective and appropriate for the service. 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. There was a clear commitment to community advocacy, partnership working, and system engagement to address health inequalities and sustainability. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system.

This service scored 93 (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. The provider had adopted an innovative and proactive approach to reducing health inequalities within its practice population. For example, they carried out targeted engagement activities, such as hosting sessions at the local mosque and conducting outreach at a local Slovak church. These initiatives successfully supported underserved groups and helped improve participation in national screening programmes.

We found there was an inclusive, positive learning and improvement culture within the practice. Leaders demonstrated a strong and unwavering commitment to driving improvement. They spoke with clear passion about the progress they had made and their plans for future development. They had a well‑defined vision for the practice and the role it aimed to play within the community.

There was a clear culture of continuous improvement, with staff given the time, support and resources needed to test and implement new ideas. Staff were highly positive about the culture the new provider had established. We found that the practice had a strong ethos of investing in its workforce to support good continuity of care and to develop and maintain a sustainable service.

The practice had a mission statement. Leaders had discussed this with staff during a practice learning time session. Providers recognised there were areas that required strengthening, further development and improvement and had plans in place. For example, plans to co-locate the administration and reception team to provide more flexibility, opportunities for learning and efficiencies and community engagement with communities that had not yet been targeted such as the Slovak community. The providers business plan reported on where they were at and where they wanted to be.

We found there was strong, highly regarded leadership within the practice. Staff reported very strongly of being valued, and the family feeling of the practice. They described acts of compassion. This was highly valued by staff and reflective of the approach taken in the practice more generally. Such feedback was replicated by patients. A room at the practice had been created as a relaxing space that could be used by staff and visitors to the practice if needed. It was arranged with comfortable seating, literature and a coffee machine. We observed a patient using this on the day of the site-visit.

The service had exceptionally 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. The partners demonstrated they had the skills to lead effectively and encouraged ideas and innovations from their staff as well as external partners. Those leaders new to their role actively sought support and guidance to enable them to enhance their knowledge and experience. They were open and honest about asking for help when they needed.

Staff told us leaders in the practice were approachable and responded to any concerns raised. We observed this during the site-visit. Records showed staff were consulted with and encouraged to speak up to help learn and improve.

There was positive feedback about leaders in the practice from other healthcare professionals that worked in partnership with the practice. We saw the leadership team were engaged in the development of primary care services within the local area. They actively raised the profile of the practice and the challenges the patient demographic faced. For example, following a complaint raised to the local Member of Parliament (MP), the practice invited the local MP to visit the practice which took place late in 2025.

Equality and human rights approaches were embedded in everything the practice did and were understood by all staff.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. We were told by multiple staff members that the ability to speak up and the culture of encouragement to do so had considerably improved in the last 12 months. They spoke of an ‘open door’ inclusive and supportive environment where speaking up was encouraged.

The practice had established Freedom to Speak up arrangements internal and external to the practice. Staff were aware of how to raise concerns. We were not provided with any evidence where staff had needed to access this arrangement.

The service strongly valued diversity and had built an inclusive, fair culture that promoted equality and equity for all staff. Leaders recruited staff from a wide range of backgrounds, resulting in a multi‑cultural and diverse workforce reflective of the communities served. Clear policies supported equality and diversity, and leaders acted promptly when concerns about discrimination were raised. Reasonable adjustments were routinely made to ensure everyone could thrive, including tailored support for disabled staff. The practice actively celebrated a wide range of cultural and religious events, fostering an inclusive environment where diversity was genuinely valued. Inspectors observed that staff were provided with protected time and space to pray, reflecting the organisation’s commitment to respecting individual beliefs and needs.

All members of the workforce—regardless of role or employment status—were offered meaningful opportunities for wellbeing, development, and career progression. This consistent and proactive approach contributed to a diverse, supportive workplace where staff felt respected, encouraged, and valued.

This strong, inclusive culture also enabled the practice to better understand the health inequalities affecting the local community. Staff were able to identify individuals at risk of experiencing barriers to healthcare and develop targeted initiatives to address these challenges. Examples included participating in research programmes relevant to their patient population, building relationships with local community groups, and working alongside charitable organisations to improve screening uptake and Citizens Advice Centres to support patients experiencing financial hardship or negative household budgets.

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 almost all the staff we spoke with confirmed this. Staff were clear on their individual roles and responsibilities. Managers met with staff to complete appraisals and performance reviews. Feedback from patients was exceptionally positive with regard to the way they were treated by staff.

The provider’s governance systems and processes were largely effective and suitably designed for the service. While some elements—such as the automated filing of blood results—were still being developed or reviewed, leaders demonstrated a proactive and transparent approach to improvement. Recruitment checks were mostly in line with national guidance, though some assurance processes for locum staff required strengthening. Importantly, the provider responded promptly to these findings and implemented improvements to enhance oversight and ensure robust compliance moving forward.

Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical and non-clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. A risk register was maintained.

We found there was a whole practice approach to governance, with staff clear on how they could contribute and support good governance processes.

Performance management processes were effective, reviewed regularly, and staff performed their roles in line with best practice. For example, consultation audits were regularly completed. Where performance was not at the expected level, this was identified, a plan put in place to address the areas of underperformance. This was reviewed and if the expected improvements were not made and maintained, appropriate action was taken to address this.

Staff were recognised and thanked for their contribution. There were staff recognition schemes to identify and reward staff.

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. There was a clear commitment to community advocacy, partnership working, and system engagement to address health inequalities and sustainability. The providers demonstrated a commitment to raising the profile of the practice and through sustained engagement with community groups, voluntary organisations, and local system partners, we saw evidence that the practice’s model of care and community-focused outreach work gained wider recognition at a civic level.

The practice demonstrated strong and proactive partnership working with a wide range of organisations to try and address the complex needs of its vulnerable patient population, including those affected by deprivation, social isolation, insecure employment, housing instability, and limited access to healthcare. This collaborative approach also aimed to raise the profile of the practice and the challenges experienced by the practice and the community. The practice’s engagement had attracted interest from the local Mayor resulting in an engagement meeting, and in a response to a complaint made to the local MP they had invited the MP to visit the practice to increase awareness and understanding of the issues faced.

Positive feedback was received from external partners, including the Community Matron Team in Rotherham, local care home providers, and the local mosque, highlighting the strength of collaboration and joint working.

The provider acknowledged that this work would continue to be developed and engagement with other communities in the patient population was planned. New initiatives put in place in collaboration with others, such as the PCN would be reviewed.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Over the past 12 months, the provider demonstrated a strong and sustained commitment to continuous learning, improvement and innovation. This work was supported by structured governance arrangements and meaningful involvement of staff, patients and partner organisations. Evidence presented throughout the report showed that these initiatives had led to measurable improvements in patient access, strengthened workforce capability and improved patient outcomes. They also contributed to greater sustainability and long‑term resilience within the practice.

Leaders and staff actively sought advice, learning and support from external organisations, and worked collaboratively with partners across the local system to enhance the quality and safety of care. New staff recognised where they needed the support of others and confidently sought advice and support from others both internal and external to the practice. Other agencies involved with the service gave positive feedback about the provider’s open, proactive and cooperative approach, highlighting improvements in communication and joint working.

The provider had an up‑to‑date business plan with defined goals, measurable outcomes and clear oversight arrangements. Inspectors saw evidence that progress was reviewed regularly, actions were delivered as planned and the business plan was updated to support further improvement. Leaders continued to explore new ways of working to benefit patients and demonstrated a clear understanding of both the service’s current position and future direction. For example, the provider had contacted the sexual health clinic to explore options for upskilling and training staff so that the practice could offer coil fitting service as for some of the community accessing the current clinic was difficult with public transport.

The service maintained a clear focus on addressing health inequalities and improving outcomes in population health and healthcare. Multiple examples referenced across the report showed how this focus had been translated into practical action, resulting in measurable benefits for patients and improved access for underserved groups. Staff and patients also provided highly positive feedback about the changes introduced by the new provider, noting the meaningful difference these improvements had made to their experience of care, in particular access to the service.