Warmdene 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.

All staff had contributed to the development of the practice vision and strategy, and this was last reviewed in June 2025.

A strategic business meeting in March 2026 considered succession planning at the service and a recruitment campaign was started as a result to ensure leadership positions were filled for the future.

The service had started a recent staff survey which was initiated in August 2026. We noted that 12 responses had already been received and all responses were positive. Feedback included positive comments about the current values of the service alongside training, scope of role development and the speaking up culture.

The service was aware of potential increases in the local population. The service told us they had a high number of families, elderly population, under 5’s and middle-aged women compared to national average.

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.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. There were guidelines and documentation that showed who was responsible for certain areas of the service. There were escalation pathways for information of concern and a freedom to speak up process

Managers met with staff regularly to complete appraisals and performance reviews. Appraisals were the responsibility of a designated GP or manager depending on the department staff worked in. Records we reviewed showed that 100% of staff had completed an appraisal in the last 12 months.

Staff we spoke with could access required policies and procedures. Clinical and non-clinical policies were reviewed by designated GPs.

Managers held regular meetings with staff. Meetings covered each department and covered key areas of the service such as Safeguarding, significant events, complaints, and frailty. We reviewed a sample of meetings minutes which showed that the service had oversight of risk, performance and outcomes.

Staff took confidentiality and information security seriously. The service had a nominated Caldicott guardian (a person responsible for protecting the confidentiality of people) and had completed data protection schemes to ensure people’s information was managed safely. Staff were observed leaving computer terminals secure when they left their desk.

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.