Parkwood 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. We found that leadership and governance at the practice was not consistently effective. At the April 2025 assessment, there were significant weaknesses in leadership oversight, partnership working and governance. The deterioration in partner relationships resulted in unclear accountability, inconsistent decision‑making and the absence of a shared vision. Systems for identifying and managing risk were ineffective and leaders did not have sufficient oversight of safety, quality, staff wellbeing or patient experience.

Staff reported limited support, poor communication and a lack of psychological safety, with ineffective arrangements for speaking up. Learning from incidents, complaints and audits was inconsistent and not embedded.

Following the assessment, improvements were made with support from the Integrated Care Board, including the appointment of a full‑time practice manager, clearer leadership roles and the introduction of structured action planning. However, at the time of re‑assessment in September 2025, these changes were not yet fully embedded and remained reliant on external oversight. Further work is required to strengthen governance, embed learning and develop a stable, open and inclusive leadership culture.

The provider was in breach of legal regulation in relation to good governance and the provider has been rated requires improvement for providing a well-led service.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The partnership relationship had deteriorated to the extent that leaders were not working towards a common goal. Staff described contradictory instructions from partners, unclear accountability and an absence of agreed priorities. Staff were concerned that senior leaders were spending time on non-clinical priorities instead of seeing patients. As a result, there was no practice vision and strategy. There was no Statement of Purpose despite this being a registration requirement and there was no succession planning taking place at the practice. We found the culture of the practice as disorganised and without strong leadership.

After re-assessment in September 2025, we saw evidence of succession planning. The practice were now working diligently to develop a robust business plan looking into long term sustainability via a 1-3 year plan. They had recruited 2 salaried GP's with a view to increase the GP partnership at the practice.

A key improvement was also the appointment of a full‑time, experienced practice manager prior to the re‑assessment. This role provided visible leadership, improved coordination and clarity around operational accountability. Staff told us this had helped reduce previous inconsistencies and had begun to restore confidence in day‑to‑day decision‑making. The practice manager had submitted a Registered Manager application with CQC which would further aid in sustainability and service recovery.

This represented a shift from reactive day‑to‑day management toward a more strategic and collective approach to the future direction of the service, which had previously been absent. However, cultural change was still heavily reliant on external oversight and the momentum of the weekly action plan progress report. The ongoing improvements needed to be fully embedded into routine leadership behaviours and governance systems. Further work was also required to ensure a consistently shared vision, strengthen partnership working at senior leadership level and the embedding of a positive, inclusive culture across the whole practice.

Before the assessment, we received multiple concerns from staff and patients regarding the leadership culture at the practice. The practice could not retain staff and many clinicians had resigned within 6 months. We also received concerns of inappropriate activity recording which undermined integrity, credibility, accountability and trust in leadership.

Several individuals reported that leaders appeared unresponsive and indifferent to concerns raised. They showed minimal support for salaried GPs, which contributed to a high turnover of clinical staff and reduced appointment availability. This directly affected patient satisfaction and continuity of care. They were perceived as indifferent to the ongoing operational and safety concerns and appeared to support these practices. The partnership relationship had become increasingly dysfunctional and unprofessional, which undermined effective leadership, damaged staff morale and adversely affected the overall operation and reputation of the practice. The sustained dissatisfaction expressed by both staff and patients indicated systemic leadership and governance failures that required urgent attention.

On assessment in April 2025, we found systemic failures in leadership. The practice did not have a dedicated practice manager and lacked a clear management structure. The leaders did not have insight into the severity of the issues in the practice and we found there was a lack of credibility to lead with integrity, openness and honesty. There was also insufficient oversight to identify and address significant operational risks which placed the delivery of safe and effective care at risk. For example, we were informed of an incident the day before the assessment where a locum GP failed to attend their scheduled shift, leaving 5 patients waiting. The leaders were not aware of this and staff told us they were unsure how to respond and when they sought guidance, leaders were unable to provide clear instructions. The locum later agreed to return and see the patients but the delay highlighted gaps in contingency planning and communication systems.

Following the re-assessment in September 2025, the practice met with staff and the Patient Participation Group (PPG) to discuss the findings. However, leaders did not provide an accurate account of the issues identified. During the June and July 2025 PPG meetings, they stated the assessment had gone well with no significant concerns and attributed it to exaggerated negative feedback. This was inconsistent with the assessment findings.

The practice also lacked transparency regarding GP retention and the absence of permanent leadership. Evidence indicated that departing GPs had raised patient safety concerns and how they felt unsafe working at the practice. There was also insufficient clarity on the number of clinical sessions delivered by the lead GP, with reports suggesting time was prioritised on non-clinical tasks. During assessment, session data provided was inconsistent and overall findings confirmed the practice was unable to meet patient needs.

At the re-assessment in September 2025, we also found the attitude of the leaders towards the issues we found on assessment and the culture in the organisation begin to shift and improve. Positive changes were being made to the practice. They recruited a full time and experienced practice manager who took part in the follow up assessment and weekly action plan meetings. There were no clearly defined roles and accountabilities for the leaders. We also found the new practice manager redeployed staff and they had been reverted back to their previous roles. Staff wellbeing was now a focus.

Prior to the assessment, we received concerns indicating that staff did not feel able to raise issues internally. Staff reported fears that speaking up could jeopardise their job security and concerns raised with leadership were often dismissed or left unresolved. There was no designated Freedom to Speak Up Guardian in place, which further limited staff confidence in reporting. As a result, staff were resigning from the practice and some staff escalated concerns externally.

We also noted reports that prior to the assessment, leaders distributed questionnaires instructing staff to present a united front, which may have contributed to a culture of fear and discouraged openness. As a result, we were not assured that staff felt supported to speak up or that the leadership promoted a transparent and safe environment for reporting concerns.

As part of this assessment, we distributed confidential staff feedback forms to gather insights into their experiences of working at the practice. This approach enabled us to capture individual perspectives that might not typically be shared during routine assessments. We received a few responses which indicated a mixed culture regarding speaking up. Staff feedback about the culture of kindness, compassion and dignity was mixed, with some describing supportive, positive working relationships where their group of staff got on very well and they would rather not get involved in disputes, while others reported feeling unsupported, contributing to high staff turnover. Some comments highlighted that previous leadership styles were perceived as confrontational and intimidating, which staff felt discouraged open communication and reporting of concerns.

The practice did not have a whistleblowing policy in place and training records indicated substantial gaps in freedom to speak up training. Only 10 non-clinical staff and 1 clinical staff member had completed this training out of 31 employees. In addition, regular staff meetings were not being held which limited opportunities for communication and speaking up. Staff feedback on assessment also described communication within the practice as poor, contributing to a culture where concerns were not consistently raised or addressed.

Following the assessment, whilst some improvement was noted, further work was required to embed a culture of openness and psychological safety across the organisation. Staff were required to complete Freedom to Speak Up and bullying and harassment training. Leaders confirmed they operated an open-door policy and encouraged staff to approach the GP partners and the practice manager openly with any personal or work-related matters, where support or reasonable adjustments may be required. Admin team meeting minutes showed staff were informed about the external Freedom to Speak Up Guardian, although we could not confirm that all staff received this information.

Meeting minutes after the assessment showed that the team discussed the importance of maintaining a respectful work environment. Staff were reminded to treat colleagues with kindness and to speak up if they felt they were not being treated fairly or listened to. The practice promoted open communication and a culture of mutual respect, acknowledging that occasional disagreements could occur.

We did not see evidence that the practice consistently promoted or actively worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Prior to the assessment, we received concerns of unfair treatment leading to stress related illnesses.

There was no equality, diversity and inclusion policy in place at the time of the assessment and leaders could not demonstrate how equality considerations were embedded into the practice. Staff told us concerns relating to unfair treatment and clinical safety were repeatedly raised but were often dismissed or not acted upon, contributing to stress‑related illness and poor morale.

There were gaps in equality and diversity training, with only 2 clinical staff fully up to date and 3 non-clinical staff overdue. These training gaps meant the practice could not assure themselves that all staff had the knowledge required to recognise shortfalls in discrimination or inequitable practices in the workplace or in patient care.

The practice had a diverse workforce but as there was no routine monitoring or analysis of workforce data, such as staff turnover, sickness, grievances or exits as part of their equality management, they could not identify potential disparities or inequities. The lack of structured governance and oversight made it difficult for leaders to identify patterns of disadvantage or exclusion affecting particular staff groups.

The practice did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At the time of assessment, the practice did not have clear responsibilities, roles, systems of accountability and good governance. We found the practice had experienced significant operational and leadership concerns. Key management roles, including the operations officer and assistant practice manager were vacant and had not been replaced or advertised, resulting in these responsibilities being dispersed across an already overstretched administrative team.

In addition, we received a significant number of concerns that some of the leadership working patterns were taken in a fragmented manner, in a way that affected their clinical responsibilities, including reviewing laboratory results, processing correspondence and supporting allied health professionals during emergencies, which in turn contributed to increased pressure on staff and undermined safe and effective service delivery.

Furthermore, concerns were raised that neighbouring GP surgeries had closed their lists to new registrations due to an influx of patients leaving the practice. As a result, patients who wished to leave the practice because of care concerns were unable to do so, limiting their ability to exercise choice and control over their healthcare.

There were gaps in governance structure which included sharing and learning culture, medicines management, significant events, legionella assessments, complaints and listening to people. Not all staff were aware of the business continuity plan and regular staff meetings were not taking place. There were gaps in the practice’s safeguarding processes and risk management systems, which had placed and caused vulnerable patients at further risk of harm. Staff did not take patient confidentiality and information security seriously.

At the re-assessment in September 2025, the practice had recruited a full time practice manager and the different types of staff meetings were reconvened, including whole staff meetings, admin meetings; however they were sporadic, some meeting minutes did not contain much information and governance systems of oversight required further improvement. For example, meeting records showed the practice did not have a formal induction or information‑sharing system for locum GPs, which resulted in inconsistent awareness of safeguarding referral processes and increased the risk of delays or failures in the management and follow‑up of urgent referrals, particularly for short‑term locum clinicians.

We also saw evidence that since the assessment, the practice had clarified roles, responsibilities and accountability through a formal governance structure. Named clinical and non‑clinical leads now provided oversight for key risk areas, with regular reporting to the partners and the practice manager providing operational assurance.

Improvements had also been made to maintain a safe environment and carry out the various safety risk assessments, although oversight was still required to ensure these assessments were assigned to and signed by a responsible individual.

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 practice was part of the Beta Primary Care Network (PCN) Network with 2 other surgeries, who they worked with to provide additional staff such as, 2 social prescribers, a mental health worker and a physiotherapist.

The Patient Participation Group (PPG) was very active with 15 members whose collective thoughts and ideas helped to improve the practice through collaboration with patients. They worked in partnership with the practice through monthly team meetings to gather patient views, discuss progress and put forward ideas for improvement. Whilst we did not speak to individual PPG members on assessment, we viewed the information they provided including published meeting minutes on their ‘Friends of Parkwood Surgery’ website.

We saw the PPG had reported ongoing concerns about poor communication with the practice and they received feedback from patients regarding difficulty securing appointments, long phone waiting times and inconsistent updates from the surgery. While they recognised wider NHS pressures and GP unsustainable workloads nationally, they emphasized that patients’ own health needs must still be met. After meeting with the practice manager, a new schedule of regular meetings was agreed for the coming year and the PPG expressed hope that communication and collaboration with the surgery would improve going forward for the benefit of their patient population and staff. The PPG were keen to fulfil their role as the practice representatives more effectively.

The concerns raised by the PPG were consistent with our assessment findings. We found that the practice was not always open or transparent with the PPG about key issues, including the rationale for the CQC assessment and the findings that emerged from it. For example, in July 2025 PPG meeting minutes, the partners told them there were no serious or significant issues identified, which was incorrect as they failed to disclose a Letter of Intent to carry out enforcement action which we had issued to the practice.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. The overall feedback we received prior the April 2025 assessment indicated the practice had not sustained a culture of continuous learning or improvement and leadership changes negatively impacted the organisation’s ability to maintain previous standards of care. People told us the practice had previously functioned well, even under high demand but that changes in leadership and management had contributed to a notable decline in service quality.

The April 2025 assessment identified systemic failures in management of risk, governance, leadership, access, medicines management, and safeguarding. This demonstrated that historic ways of working were unsafe and unsustainable. The scale of backlogs, workforce instability and poor oversight showed that risks were not being identified, escalated or managed effectively and that learning from incidents, patient complaints and staff feedback were not embedded.

The practice demonstrated a willingness to improve and undertook collaborative working with the local ICB and implemented an action plan, prioritised high risk areas to tackle the backlogs, including outsourcing document management, recruiting a dedicated GP for Docman tasks, daily monitoring of results and a structured allocation of workload to reduce unactioned correspondence and pathology results.

The practice pharmacy team in collaboration with the GP partners also created a strategic action plan that outlined remedial actions completed to date, progress in mitigating identified risks and a structured, time-bound framework for ongoing implementation.

Leadership changes, including recruitment of a full‑time experienced practice manager, enabled the reintroduction of staff meetings, clearer role allocation and early steps to rebuild governance and organisational learning.

At the September 2025 re‑assessment, there was demonstrable improvement in some core safety systems, including clearance of pathology backlogs, improved management of urgent referrals, improved safeguarding identification and a recruitment drive to stabilise staffing levels. They also had an improvement plan to help drive improvements in the appointment system. All staff were encouraged to put forward and test out new ways of working, and we saw examples of this with the nursing staff.

However, despite improvements, learning was not yet embedded or systematic. They had not finalised an established culture of continuous learning, as there continued to be limited evidence of 2‑cycle audits, multidisciplinary meetings and routine clinical meetings to review outcomes and update practice in line with evidence‑based guidance. Significant event analysis remained inconsistent, poorly documented and lacked clear evidence of shared learning or sustained change.

Overall, the practice demonstrated capacity to learn when subject to external oversight; however, learning remained fragile and dependent on external direction rather than fully embedded internal systems and culture. The practice acknowledged the need for ongoing monitoring and further embedding of the improvements being introduced.