Dr Amrish Gor Also known as Havergal 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 the practice’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good.

At this assessment, we focused on 2 quality statements relating to the key question Well-led: Shared direction and culture and Governance, management and sustainability.

At this assessment, the rating remains the same.

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 practice had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

Staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The practice was aware of local challenges which affected the service and worked with partner agencies to address them. We saw the practice had a detailed business plan, setting out its strategic direction, priorities, governance arrangements and improvement programme for the next 3 years.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development. The feedback we received from 14 members of staff supported this. They described a very positive and supportive working environment.

The practice operated with a Virtual Patient Participation Group (PPG), and we were shown the results of 2 in house patient surveys in 2025 and 2026 conducted with the PPG and from which the practice had developed improvement action plans. These included issues such as access to appointments, telephone waiting times, and communication. We received feedback from 6 members of the PPG. While most said the practice worked well with the PPG to listen to feedback and work to improve services where possible, some thought the current PPG working model was limited. It did not have formal meetings, with an opportunity for members to regularly explore issues in detail with the practice. The meetings had been put on hold during the COVID pandemic. We discussed with the provider whether there was scope to improve engagement and the effectiveness of the PPG. They confirmed they would reflect on the issue with a view to reintroducing regular PPG meetings moving forward.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The practice had clear responsibilities, roles, systems of accountability and good governance. It used these to manage and deliver good quality, sustainable care, treatment and support. It acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We received feedback confirming staff members were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews.

The practice had put in place a suite of governance policies in relation to its operation. We saw there was a planned schedule for reviewing the policies to ensure they were updated to reflect latest guidance and that they were shared with all staff.

Leaders held regular meetings with staff, during which they reviewed performance data and discussed emerging risks and potential improvements to the service. Leaders clearly recorded any actions that arose from these meetings and shared these with staff. Staff took confidentiality and information security seriously. Staff submitted data and notifications to external agencies as required.

We saw evidence of staff receiving governance training relevant to the roles and responsibilities, such as Information Governance, the Mental Capacity Act, and Reasonable Adjustments. Some staff members had also undertaken Coaching for Health training, intended to encourage and support people to take ownership of their health, both generally and in relation to any long-term health conditions.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.