The Connaught Square Practice

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.

At our last inspection in August 2018, we rated this key question as Good. At this assessment in December 2025, the rating remains the same.

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.

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.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

Feedback from staff interviews suggested a positive relationship between staff and management, with staff reporting that they enjoyed working at the practice.

The service 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 told us leaders in the practice was 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 service 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. Staff were aware of how to raise concerns and reported feeling comfortable doing so. Those we spoke with also knew how to access the whistleblowing policy.

The practice valued diversity in their workforce. They work 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 examples of how adjustments had been made to enable staff to work effectively at the service. The practice provided training in equality and diversity, and leaders fostered an environment where staff felt confident in their roles and enjoyed their daily responsibilities.

The practice had clear responsibilities and roles. However, we found there was a lack of effective governance in some areas, which included the monitoring of some high-risk medicines, unavailability of some emergency medicines, monitoring of the prescription box for uncollected prescriptions, and gaps in recruitment checks including Disclosure and Barring Service (DBS) checks.

They did not always make sure relevant fire and legionella risk assessments were carried out by a qualified person in a timely manner.

Some staff documents were not kept in staff files.

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

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

The provider worked with other practices within their primary care network to offer extended access, and flu vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The Patient Participation Group (PPG) was not fully active at the time of the assessment. The practice had recently recruited a new practice manager, who was in the process of re-establishing the group and planning to facilitate regular meetings going forward. The PPG members we spoke with informed us that the last PPG meeting had taken place in April 2025 and the next meeting planned for 26 January 2026.

The service 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.

The practice could demonstrate how it used complaints, incidents and feedback to improve.