Gardiner Crescent 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.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to 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.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. There was now an embedded leadership team who were actively focused on leading the team to achieve the shared vision. The practice was working with partner agencies to address future challenges.

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. The practice had employed a salaried GP, which had created capacity for clinical leadership and governance at a GP level. This supported more effective governance.

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 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 with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

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

Policies and procedures to promote diversity and equality were in place. We saw senior leaders addressed any concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example, we heard about adjustments made to support the diversity of staff. For example, for those with caring responsibilities.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

In our May 2025 inspection, we found gaps in governance arrangements. This included governance and oversight of safeguarding; the effectiveness of monitoring and review of people with long term conditions; monitoring of medicines that can cause harm and the quality of medicine reviews. In May 2026, we found the provider had addressed these concerns and the governance processes were supporting good quality care.

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

The provider worked with 6 other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff coordinated their service with community healthcare services, including provision of targeted services for elderly people experiencing frailty, people experiencing poor mental health and those who would benefit from social prescribing.

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 had sustained and embedded improvements made over the last few years. They had addressed the concerns we identified in our May 2025 inspection about gaps in clinical governance and the effectiveness of monitoring and review of people with long term conditions and medicines that can cause harm. Clinical governance had improved and there were now effective monitoring and review processes for people with long term conditions and medicines that can cause harm.

The practice had embedded the quality improvements put in place previously to help drive improvements in services. All staff were encouraged to put forward and test out new ways of working, and staff shared with us areas they had been able to influence and improve. For example, staff were involved in developing and implementing improvements following the last inspection to support the practice to achieve compliance.