Burdwood 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 inspection, we rated this key question as Good. At this inspection, 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, a 3-year strategy, a strategic aim and an inclusive culture. This was based on 5 separate principles:

• Patient-centred care
• Continuity of care
• Continuous improvement
• Workforce development and well-being
• Innovation and digital adoption

Staff and leaders understood the challenges and the needs of people and their communities. Leaders emphasised how all elements of the practice were under constant review to ensure services were appropriate for the changes within the population and the wider primary care sector.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. This included a dedicated staff session in May 2025 which focused on how every staff member contributed to the overall direction and development of the practice. Leaders monitored and reviewed progress against the delivery of their strategy. The practice was aware of local challenges which affected their service, such as changes within primary care and the projected increase in the local population over the coming years and worked with partner agencies to address these challenges.

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.

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. They used these to manage and deliver high-quality, sustainable care, treatment and support.

Sustainability, succession planning and future proofing of the practice was a standing item at business meetings. Leaders always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

All staff were clear on their individual roles and responsibilities and knew how and when to raise concerns. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for their service. We saw the practice used equality impact assessments to ensure policies or processes did not present barriers to participation or disadvantage any protected groups. 

Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff, during which they 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, which included verifying people’s identity during remote consultations. Staff submitted data and notifications to external agencies as required. This included CQC when making changes to their CQC registration.

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.