Cricklade Surgery

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• 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 inadequate.

The service was in breach of legal regulation in relation to good governance.

This service scored 29 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. For example, senior leaders did not always ensure policies were up-to-date, available or include the names of designated leads.

Staff meeting minutes were not consistently available, and there were no standard agenda items in place. External meeting minutes that were reviewed did not record attendance, so it was unclear who was present for key discussions.

Internal staff meeting minutes were not provided during the inspection, and there was no evidence recent events within the service such as complaints, significant events, or lessons learned, had been discussed with staff or recorded.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Staff told us there was a need for better communication across teams and for the leadership team to be more visible and engaged with staff. They expressed a desire for improved engagement with senior management and a clearer understanding of the service’s overall vision.

Staff also raised concerns about the lack of supervision and appraisal support from leaders.

People did not feel they could speak up and that their voice would be heard.

The service had a ‘freedom to speak up’ policy but this was dated 2022 and referred to outdated terminology. For example, clinical commissioning group (CCG) contacts were still listed, despite became integrated care boards (ICBs) coming into effect in July 2022. There was no clear mechanism to ensure staff had access to current guidance on how to raise concerns, and no visible information within the service to direct staff to the appropriate contacts. This meant there was no information for staff about raising concerns safely should they need to.

Staff we spoke with described examples of significant events that had been escalated; however, no evidence of these being reported, recorded and investigated was available during our on‑site visit. Staff told us they did not feel confident that concerns raised would be responded to.

The service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service did not have effective systems in place to engage and involve staff. For example, no staff surveys carried out by the service to gain feedback from staff were available to be reviewed during the inspection.

The service also lacked effective systems and processes to assess, monitor and mitigate risks relating to staff health, safety and welfare. In line with the Health and Safety (Display Screen Equipment) Regulations 1992, staff who use display screen equipment as part of their role should have workstation assessments to ensure ergonomic safety. However, 4 out of the 6 staff files we reviewed during our on‑site visit contained no evidence of these assessments having been completed. This created a risk of staff working in an unsafe environment, and potential health or safety issues were not being identified or addressed.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not have effective systems and processes to confirm that staff recruitment complied with Schedule 3 of the Health and Social Care Act 2008. During our visit, we reviewed 6 staff files, which did not demonstrate that the required information was held to ensure suitability for persons employed in regulated activities. There was also no evidence that appropriate inductions, supervision, or appraisals were taking place as necessary to enable employees to carry out their duties safely and effectively.

The service did not have an immunisation policy, and there was no system to ensure oversight of staff immunisation status.

There was no established system or process to oversee staff training, including the recording, monitoring, and completion of required modules. The service’s training policy did not identify what it considered mandatory, and the service was not adhering to the policy regarding the identification of training needs.

There was no oversight from leaders to ensure mandatory training and role-specific training was being planned, reviewed or tracked effectively. Several modules were overdue or incomplete for staff across both clinical and non‑clinical roles.

Governance and oversight of training and staffing were not effective. The service operated at times without a clinician on site, and there was no effective mitigation in place for this risk. The service stated that their mitigation was ensuring all staff had up‑to‑date basic life support (BLS) training, but this was not monitored or assured. The training matrix showed that most staff did not have current BLS training, meaning the service had neither identified nor addressed this risk. As a result, the service could not demonstrate safe arrangements or assurance that staff would be able to respond appropriately in an emergency.

The service was not following its own policies for staff supervision and appraisal, and it was unable to demonstrate that effective governance processes or designated leads were in place.

The service did not have an effective system to assess, monitor, or make improvements. Leaders did not have a process or designated person to monitor complaints or significant events, which meant they could not demonstrate that appropriate actions had been taken. One example had recommended actions from two months before our onsite and the review had still not been completed. The service was unable to show that risks had been mitigated or that learning had been identified, implemented, and shared.

The service was unable to demonstrate that complaints were being managed effectively, as there was no agreed process in place and they could not identify how many complaints had been received in 2024 or 2025.

The service was unable to demonstrate awareness of its mandatory reporting requirements under NHS England’s Strategic Data Collection System (SDCS), meaning it had not fulfilled its duty to submit the required data to NHS England.

The service did not ensure there were effective systems in place for infection, prevention and control (IPC), health and safety, fire safety, safeguarding, or emergency medicines following the departure of previous members of staff to ensure continued oversight of these areas.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service was part of the primary care network (PCN) and offered extended access once a week until 8pm, delivered through a nurse‑led clinic.

However, the service was unable to tell us or provide any evidence that meetings with the PCN or other services and organisations were taking place to ensure seamless, well‑coordinated care for people using the service. There was also no evidence of engagement with people, the community, or partner organisations to support shared learning or drive improvements.

The service was, however, able to demonstrate that referrals were being managed appropriately, which did indicate joined‑up working with secondary care services, such as hospitals.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. We saw a lack of a learning culture, for example, staff did not feel they could raise concerns, and they be followed up. We also heard accounts of significant events through our conversations with staff but could not find evidence these had been reported, recorded and investigated to learn from to prevent recurrence.