The Spa 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 good. At this assessment, the rating remains the same.

This service scored 86 (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. The practice had annual "time-out" for teams. This was used for staff to come together to discuss how to continue to develop and improve the service. The 2025 "time-out" was utilised to develop the practice's vision. This was shared internally at the practice, across social media platforms and with the patient participation group.

Most staff felt they had contributed to the development of the practice vision and strategy, which was kept under review. The practice had undertaken yearly staff wellbeing surveys since 2023, and actions had been taken where necessary. For example, some team members had felt burnout at times, therefore the practice had increased capacity and improved training and support for current team members.

Staff feedback we received was mostly positive about the future of the practice. All staff we spoke to felt positive about working at the practice.

Staff described good working relations and a service that was clear on its function to work in the interests of patients, providing the best possible experience.

The service had exceptionally 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 always did so with integrity, openness and honesty.

Staff had annual appraisals which included using 360 degree feedback. Appraisals were utilised to set objectives and personal development plans for staff. These were regularly monitored through 1 to 1 meetings and a 6 monthly check in.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice, and the focus was on staff wellbeing.

Leaders had identified the need to develop a pharmacy team to deal and manage medicine related queries. As a result of this, GPs had more capacity to manage complex clinical care cases. Feedback from staff showed this had also improved their work life balance.

The practice had a clear focus of developing and retaining staff. We saw examples of how staff had started working at the practice on entry level jobs before progressing and developing into clinical or management roles.

We saw the leadership team worked with other practices in the PCN 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 within their own practice. There were 3 Freedom to Speak up Guardians in the practice and all had received relevant training.

There are no specific regulations governing a practice’s freedom to speak up arrangements, however, a provider must evidence freedom to speak up policies and practice. Most practices have an agreement with their PCN regarding Freedom to Speak up arrangements but staff at the practice were aware of how to raise concerns, and staff questionnaires highlighted that staff were aware of Freedom to Speak up arrangements.

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. Staff told us they felt supported, were treated equally and were free from bullying and harassment.

Policies and procedures to promote diversity and equality were in place. The practice regularly reviewed working patterns to account for cultural and religious events. There was also a dedicated space available for staff to use for prayer.

A review of staff training showed that staff had completed training on equality and diversity.

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

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 via the sharepoint computer system.

Risk assessments had been carried out including monthly Health and Safety inspections which are done by a centralised Facilities Manager.

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 practice took sustainability seriously, this included having recycling and compost bins available in break rooms. Staff were able to join the "cycle to work scheme".The provider had also substantially reduced reliance on certain inhalers in line with environmental considerations.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

The practice engaged and pro-actively worked with Disability Action to review access to the surgery. They had also been invited to attend a local disability forum.

The practice was supported by an active PPG. The PPG met bi-monthly at the practice. Minutes from PPG meetings were displayed within the waiting rooms so that other patients could see what had been achieved through the meetings. Through engagement with the practice, the PPG had reviewed message wording that was sent to patients. They had also created a patient information pack and been involved in the design of the practice's website. Digital access support appointments were created following feedback from the PPG. These appointments allowed patients to make appointments with care navigators in order to learn how to use digital platforms such as the NHS app.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 identified that monitoring and managing patients with hypertension (high blood pressure) required improving due to manually interpreting blood pressure readings alongside NICE guidelines which could potentially lead to inconsistent results. An automated workflow was created that instantly evaluated blood pressure readings against NICE guidelines, it took into account patient specific factors such as age and comorbidities. Depending on the results it then displayed clear next steps for administration staff when processing. This created a consistent approach, and resulted in time saved when entering blood pressure readings, unnecessary appointments avoided and an improved patient journey with more consistent care. This was shared with the developer of the practice's clinical system, who then displayed it on their website for other practices to learn from.

The practice had a quality improvement plan in place to help drive improvements in services. They had focussed on the appointment system and introduced a ‘blended model’ appointment system which included the development of a care navigation toolkit to support safe, consistent and clinically approved signposting by the administration staff alongside the clinical triaged based system. The practice had implemented a "VIP telephony prioritisation process". This ensured that patients who were clinically coded appropriately were prioritised for telephone access.

We saw that the practice had invested in AI technology after completing the associated risk assessments. This was utilised for GP transcribing services and to create approachable accessible videos for patients.

Staff felt encouraged to put forward and test new ways of working.