Friary House 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

This is the first inspection for this service since its registration and change to a new provider with CQC. This key question has been rated as requires improvement. We assessed all quality statements in the well-led key question.

The service was in breach of the legal regulation relating to good governance and failure to notify the commission of registration changes relating to the legal partnership and when a registered person ceases to carry on or manage the regulated activity. We found there was a lack of overarching and effective governance in regard to regular and documented clinical supervision, business/MDT and team meetings were inconsistent therefore learning could not be shared. Systems and processes for the reporting of complaints and significant events required embedding.

This service scored 57 (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 and mission strategy which was promoted on their website. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and the local community.

CQC received 11 staff feedback surveys. The majority highlighted that staff were unclear about the vision of the service. However, the service also shared with us a “statement of improvement plan” that would be reviewed regularly and had been written in response to concerns raised around appointment availability and accessibility. However, this had only just been created and had not had time to be embedded within the service.

Staff told us that there was a positive team culture within the service and staff all tried to help each other where possible, they shared a common aim to do the best they could for patients and strived to provide safe, high-quality, and compassionate care.

Leaders did not always recognise the impact in which the service delivered care, treatment and support. Staff told us there was not a clear understanding of the role of the Central Office and a disparity of how the practice operated at local level, including unrealistic workloads to carry out tasks relating to the management of patient care. We found examples of staff dissatisfaction with employment concerns, and poor communication and support from senior leaders relating to employment issues.

Staff told us a lack of communication from the Central Office led to delays in requests for the replacement of equipment and other clinical items to ensure the smooth running of the service. This led to staff feeling anxious and concerned about providing safe care and treatment to people.

On the day of the site visit, the provider demonstrated how the Central Office team had oversight of clinical performance and workload through a cloud-based operating system. This enabled teams to visually customise and manage workflow and processes and was reviewed on a daily basis to look at tasks such as outstanding patient results, referrals, medication reviews and triage results. Remote support was provided when areas of risk were highlighted, and where possible, locum clinical staff provided cover.

The service did not always foster 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 (FTSU) and staff were aware of the nominated FTSU champion, however the individual had a conflict of interest (a conflict of interest occurs when an individual’s personal interests such as family, friendships, financial or social factors could compromise his or her judgment, decisions or actions in the workplace) and because of this staff did not always feel they could speak up. We spoke to the provider on the day of the inspection, and they agreed to pursue a second champion.

Staff told us that the practice manager was generally visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive management and leadership. However, feedback from staff and documentation showed that leaders from the Central Office were not always visible or approachable, and there were delays in responding to practice communications.

We were told by leaders that a QR code (a quick response image that can be assessed by a telephone camera) had been created for staff to provide anonymous feedback to them but to date no responses had been received.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Polices and procedures to promote diversity and equality were available to staff. Staff were able to explain their understanding of equality, diversity and inclusion and had completed training in this area.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on information about risk, performance and outcomes, or share this with others when appropriate.

Risks were not always effectively identified, assessed and mitigated in areas relating to weekly and monthly fire safety checks. Internal quality monitoring systems had also not identified the legal requirement to notify the commission of the registration changes to the service in a timely manner.

We spoke with leaders in relation to overarching governance of the practice. We were told there is a Central Office made up of staff who supported and managed the delivery of quality, complaints, human resources, compliance, IT and clinical services. Feedback from staff highlighted that communication between the Central Office and the practice was not always effective, therefore improvements were needed.

Leaders did not always meet with staff on a regular basis to complete appraisals, performance reviews and clinical supervision. We saw minutes from business meetings dated 24 September 2024, 20 May 2025 and 19 June 2025 where staff discussed clinical concerns and emerging risks however these were not yet embedded within the practice. Staff told us they were able to access policies and procedures, and they knew who to talk with if they had any concerns or questions.

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

The provider worked with other practices within their primary care network to offer extended access and flu and covid vaccination programmes.

The service did not always focus on continuous learning, innovation and improvement across the organisation. We saw some clinical audits including prescribing, but these were not carried out on a regular basis and had not been embedded within the practice.

The service had a programme of quality improvement which included the restructuring of appointments to create a more balanced and accessible mix of availability, including, face to face for routine and urgent needs, telephone/text follow up appointments, 15-minute telephone appointments for continuity of patient management, and dedicated appointments for the certification of fit to work notes. However, this had only recently been introduced and required time to fully embed, monitor and refine to streamline the appointment process.