Holly Tree Surgery

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• 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 has changed and is now requires improvement.

Due to the governance concerns identified by this assessment the service is in breach of legal regulation related to good governance.

This service scored 71 (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.

A new partnership formed in January 2026 and began developing the service’s culture, vision and strategy. Staff reported a more open and positive culture. They described leaders as available, approachable and receptive to ideas, and said leaders listened and provided feedback. Staff felt positive about the changes and the service’s future direction. Staff and leaders promoted equality and diversity, sought to identify the causes of workforce inequalities, and supported learning and development through a compassionate listening culture. Leaders understood local challenges, including the service not belonging to a Primary Care Network (PCN), and were actively exploring options to join a PCN.

Many staff worked part-time and could not always attend meetings. We saw and staff told us the service had a new process which allowed people to add agenda items in advance even if they were not able to attend the meeting and read the minutes afterwards to understand the outcome of a discussion. This was an example of how leaders were making a collaborative, inclusive and open culture.

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 did not have good governance or systems of accountability but had clear responsibilities and roles. They acted upon performance and outcomes but did not act on potential risk.

The service had some governance systems in place, but these were not effective in all areas. The service had recently formed a new partnership, and leaders were changing systems and ways of working. Because of this, leaders did not always have a full understanding of how well processes were working or where risks needed to be addressed.

For example, governance systems existed but quality assurance had not identified or addressed all concerns we found such as issues relating to the access and security of the dispensary, safe recruitment of staff, oversight of staff training and compliance, and staff immunisations. We also found systems and processes regarding cleaning arrangements were not completely effective and needed strengthening and improving. These findings meant leaders could not always be assured that systems and processes were operating safely and effectively or that they ensured good governance for the service.

However, leaders had started to improve oversight. They had already reviewed some existing processes and identified some priority areas and immediate risks requiring change and measures to control them. The service used a risk register, and this was an embedded process but not all the areas we found were recorded on it. Where risks were identified, risks assessments were used. These systems helped leaders record and maintain oversight of risks and performance.

Leaders were responsive to our feedback and during the assessment began taking action to make improvements. For example, after the site visit we were told the service was installing a new security system to make the premises more secure. We were also told about ideas being considered to improve the access and security arrangements for the dispensary and it was confirmed that there had been no incidents related to the dispensary. The service also confirmed they had completed the planned fire evacuation drill, and we saw evidence that a full review had been completed afterwards which identified how this process could be improved for the future and this had been communicated to staff.

All staff we spoke with were clear on their individual roles and responsibilities. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews.

Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders clearly recorded any actions that arose from these meetings and shared these with staff.

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.