Westfield Road 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, 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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.
Staff described a collaborative working environment where they felt valued, respected, and involved in delivering high-quality care. There was a clear focus on teamwork, shared responsibility, and open communication across both clinical and non-clinical roles.

Leaders were approachable and responsive, creating a culture where staff felt confident to raise concerns, share ideas, and contribute to improvements. Regular communication, including daily huddles, multidisciplinary meetings, and protected learning time, provided structured opportunities to discuss care, share updates, and reflect on practice. This supported ongoing learning and a consistent focus on patient safety.

Staff across all roles worked well together and supported one another in their day-to-day work. They felt able to seek advice when needed, which promoted safe practice and continuous development. A strong team ethos was evident throughout the service.
The service also showed a commitment to staff wellbeing. Opportunities for feedback, such as staff surveys, alongside team-building activities, helped to maintain engagement and morale. Staff reported feeling supported by leaders, who actively encouraged open discussions and listened to feedback.
 

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 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.
Clear processes were in place for incident reporting, risk management, safeguarding, and audit activity, and these were understood and consistently followed by staff. Electronic systems were used to monitor training, risk, and performance, providing effective oversight and enabling timely action where required.

A structured programme of clinical and operational audits supported continuous improvement. This was guided by an agreed audit schedule, supported by tracking systems and regular reviews. Learning from audits, incidents, and significant events was shared through team discussions, with actions implemented and revisited to ensure improvements were sustained. Clinical practice was informed by evidence-based guidance and relevant national and local standards, supporting consistent and high-quality care.

Administrative and operational systems were organised and worked effectively to support patient care and service delivery. Staff followed clear processes for managing patient enquiries, clinical correspondence, and workflows, ensuring information was handled accurately and efficiently. Administrative teams worked closely with clinicians to support patient pathways, prioritise urgent work, and ensure timely communication. The use of digital systems had improved efficiency and accessibility of information.
Communication across the service was strong, with clear roles, responsibilities, and escalation processes in place. Staff felt confident in raising concerns, and there were effective systems to ensure these were reviewed and acted upon. Significant events and complaints were recorded, investigated, and discussed within team meetings, with shared learning used to improve practice and reduce the risk of recurrence.

Patient feedback was actively collected through a range of channels and used to inform improvements. This included making changes to systems and processes in response to patient experience. Policies and procedures were regularly reviewed and updated to ensure they remained current and in line with regulatory requirements.
Staff were supported to develop in their roles through regular supervision, appraisals, and access to training. Ongoing support from leaders ensured staff remained competent and confident in their responsibilities.

Overall, governance arrangements were clear, effective, and well embedded, supporting safe, coordinated, and sustainable service delivery, with a strong focus on continuous improvement and patient-centred care.
 

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.