The Densham 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 Requires Improvement. At this assessment, the rating has changed to Good. The practice is no longer in breach of regulations in relation to good governance.

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.

Practice management told us there was a vision and values statement in place that guided their work, and this was displayed within the practice. Most staff surveyed agreed that the service had a clear and well‑communicated direction for the future. The service demonstrated a shared vision, strategy and culture rooted in transparency, equity, equality, human rights, diversity and inclusion. Staff described the practice as small, friendly and supportive, with an open‑door approach that encouraged communication. Regular huddles were used to support discussion and debriefing, and staff reported a supportive but productive working atmosphere. Leaders actively promoted team cohesion, and staff told us they felt supported through positive day‑to‑day interactions and informal team‑building activities.

Leaders told us they focused on staff well‑being and were responsive to staff needs. They carried out staff surveys to identify where additional support might be required, and staff told us leaders were approachable and acted on any concerns raised. The service had experienced staff bereavement within a short period, and leaders had provided support to help the team cope during this difficult time. Roles and responsibilities were clearly defined, and staff understood their accountabilities. Processes were in place to support the workforce, including arrangements for annual leave and flexible working. Staff told us leaders were approachable and modelled the values of the practice. We saw that the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where staff felt able to speak up and were confident their concerns would be listened to. Staff were aware of how and when to contact the Freedom to Speak Up guardian. The service had updated its Speak Up arrangements in April 2025, enabling staff to raise concerns directly with the practice manager from another practice within the network if they preferred. Leaders told us that, to their knowledge, no staff had accessed the Speak Up route to date, as concerns were usually managed internally; however, staff were encouraged to use this option whenever needed and reported that they knew who the guardian was. The service also had a whistleblowing policy in place, which staff were aware of and knew how to access.

The service promoted an inclusive culture where staff felt valued and treated fairly. Leaders told us they were committed to improving equality and equity within the workforce, and this was reflected in their approach to recruitment and staff support. Recruitment processes were designed to be inclusive, with applications managed through NHS Jobs via the federation, enabling anonymised shortlisting to support a more objective and unbiased process. Internal vacancies were also advertised to encourage career progression for existing staff. The workforce reflected a diverse range of backgrounds, and staff from different faiths were supported to practise their beliefs, with designated spaces provided where appropriate. Staff told us they had completed equality, diversity and inclusion training, and records confirmed this. Policies and procedures promoting diversity, equality and inclusion were in place and understood by staff. Leaders also supported staff development by offering training opportunities and providing assistance wherever possible to help individuals enhance their skills and progress in their roles.

Leaders had established clear responsibilities, defined roles and effective systems of accountability which supported strong governance arrangements. These structures enabled the service to manage and deliver good quality, sustainable care, treatment and support. Leaders used reliable information about risk, performance and outcomes to inform decision making, and shared this securely with relevant partners when appropriate.
During our previous assessment we identified concerns regarding governance issues. During this inspection we found that they had reviewed their processes and made the necessary changes. The practice had improved oversight of the work of the GP assistant. A GP was now tasked electronically to maintain oversight of their patients. Earlier coding errors were no longer occurring, and the improved process was reinforced during staff meetings to ensure it became embedded within routine practice.
Training compliance across the service was strong. All staff had completed the required training, including training on meeting the needs of people with learning disabilities. The training matrix showed full compliance, and this was further confirmed by the electronic training records we reviewed during the inspection. Staff also had access to at least 4 protected learning afternoons each year to support continued professional development and ensure ongoing compliance.

Arrangements for staff appraisals were effective and well organised. All appraisals were in place, with senior staff delegated to carry these out across different teams within the service. An electronic system provided alerts to both the appraiser and appraisee, helping ensure appraisals were carried out on time and not overlooked.

The service had strengthened its Disclosure and Barring Service (DBS) checking processes to provide greater assurance. All new starters were now required to apply for a DBS check, regardless of their previous employer, including those transferring from within the federation. Staff were also required to disclose any changes to their DBS status, and this discussion formed a routine part of the appraisal process.

The practice engaged with patients through surveys, complaints and compliments, and used this feedback to inform improvements. Leaders told us they had attempted to establish a patient participation group but had not yet been successful in recruiting members.
Staff and leaders were open and collaborative and demonstrated an understanding of their duty to work in partnership to ensure services operated smoothly for patients. The practice shared learning with partners and contributed to wider initiatives across the primary care network (PCN), including menopause drop‑in clinics and a weight‑management programme, which were delivered on site by PCN social prescribers.
The practice also hosted external organisations offering additional support, such as employment guidance services and a support worker for women experiencing domestic abuse. They provided access to period products in recognition of local deprivation.
The provider worked effectively with other PCN practices to deliver extended access and made good use of additional roles through the ARRS scheme. Staff described positive working relationships with PCN colleagues, and leaders held regular meetings with partner organisations, including safeguarding leads, to support safe and effective care. The practice contributed to the PCN’s vision and took part in discussions about future service development.
 

There was a strong learning culture within the practice, which leaders and staff actively contributed to. The practice had undergone significant change to address previous gaps in its assurance systems, and leaders told us they anticipated further development to support the long‑term sustainability of services in the area. They had also taken steps to improve access to the service by upgrading their telephony system and enhancing online access.
The practice was involved in a wide range of improvement and research initiatives aimed at reducing health inequalities, supporting long‑term condition management, and improving access to care. Their participation contributed to wider learning across primary care, supported improvements in population health, and helped the practice develop evidence‑based approaches to emerging health needs. It also supported staff development and fostered a culture of innovation.