The Dovecot 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 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 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 and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us there was an open and honest culture within the practice. They felt confident to raise concerns without fear of retribution and believed that their views were listened to and valued. Staff also said that there was a clear vision for the future.

However, some staff noted that they had not been involved in the development of the practice’s strategic planning, including the creation of its mission statement, vision, and values.

The practice had systems and processes in place that did not consistently support effective care. Governance arrangements were not consistently effective prior to the assessment; however, leaders demonstrated integrity and capability by responding promptly to concerns. New governance processes were introduced and, although not yet fully embedded, they reflected a proactive approach to strengthening systems. While improvements were evident, further work was required to ensure systems operated consistently and effectively.

Staff told us that leaders in the practice were approachable and responsive to concerns. The leadership team worked collaboratively with other practices in the primary care network. Staff feedback indicated that most felt their views were listened to, although some did not always feel their suggestions were acted upon.

To further enhance leadership capability and support ongoing improvement, the Practice Manager had applied for the Aspiring Practice Manager course, demonstrating a commitment to professional development and effective service delivery.

The service fostered 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, and staff told us they knew how to raise concerns if needed. Most staff who responded to the feedback questionnaire confirmed that they understood what whistleblowing was and how to report concerns.

The service valued diversity in their workforce and worked towards an inclusive and fair culture by improving equality and equity for all staff.

Leaders promoted open communication and maintained an open-door policy to encourage feedback. Staff had received training in equality, diversity, and human rights, and reported feeling respected in their roles.

The leadership team actively made reasonable adjustments to support staff with changing health or personal needs. Examples included flexible working arrangements, access to Occupational Health support, and the provision of equipment or workspace adaptations to improve comfort and wellbeing. The practice also supported staff to observe their religious or cultural practices, providing access to a quiet space for prayer or reflection when required.

The service did not always operate with effective governance systems to support oversight of risk, performance, and quality of care. There was no effective process for managing staff immunisation status, some policies listed incorrect leads, and mandatory training records showed gaps. Clinical oversight also required strengthening. Prescribing and monitoring were not always aligned with current guidance, and some follow-ups and medication reviews were delayed across long-term conditions, some clinical records lacked detail, and documentation for pregnancy prevention plans in patients prescribed teratogenic medicines was inconsistent.

Coding errors were identified where patients prescribed the combined oral contraceptive pill were incorrectly recorded as having a history of venous thromboembolism. The practice corrected these errors immediately.

Following the assessment, leaders responded promptly to the concerns raised. They strengthened prescribing and monitoring systems, enhanced recall processes, and completed documentation for patients on teratogenic medicines. Policies were updated to reflect the correct leads. Training gaps were addressed by setting a completion deadline, and steps were taken to improve immunisation records by offering vaccinations, completing risk assessments, and updating staff records.

Governance and communication structures had begun to strengthen around the time of the assessment. Safeguarding issues were discussed daily during clinical catchups and GP manager meetings. Although formal minutes were not recorded, individual safeguarding records were completed when needed. Leaders recognised the need to formalise these meetings for continuity and assurance and planned to combine them with palliative and frailty reviews every 6 weeks, with formal minutes recorded.

A formal process for assessing clinical competence had been introduced and was in place at the time of the assessment, though not yet fully embedded.

As the provider had recently implemented new governance arrangements, these were still in the early stages. While improvements were evident, further work was needed to ensure systems operated consistently and effectively.

Several staff worked across 2 general practices under shared management, supporting consistent oversight of governance, training, and induction. Shared policies and protocols ensured alignment, with staff following procedures specific to their location. Confidentiality agreements were signed by all staff, and access to patient data was role restricted. Regular joint meetings across both sites facilitated shared learning from incidents, complaints, and audits.

Despite initial gaps in governance, staff described the practice as a supportive place to work and most felt well managed. Appraisals were held regularly. Leaders were open and responsive during the assessment and demonstrated a clear commitment to improving oversight, safety, and sustainability.

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

The practice collaborated with partner organisations and local community groups to improve health outcomes and deliver coordinated, person-centred care. Leaders and staff actively participated in Primary Care Network (PCN) activities and contributed to the development of shared services and wellbeing initiatives across the local area.

The practice maintained positive relationships with community health and social care teams, including its aligned care home, where regular multidisciplinary meetings and ward rounds were held to review residents’ needs and coordinate ongoing support.

Strong community engagement was also evident. The practice supported local health promotion and wellbeing initiatives such as the Menopause Café, WHAM (Women’s Health and Menopause) walk-and-talk sessions, and the Choose to Lose weight management programme, which were later adopted across the PCN. The practice also supported the Hey Girls campaign, providing free period products to help tackle period poverty, and in September 2025, assisted another local practice in hosting a Macmillan Coffee Morning to raise funds and awareness for people affected by cancer.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Leaders at the practice actively supported staff development through a variety of structured opportunities and career pathways. The practice was a recognised teaching and training site, regularly hosting medical students to support clinical education and mentoring. The Practice Manager had applied for the Aspiring Practice Manager course, demonstrating a commitment to ongoing professional growth and leadership development. In addition, staff members were enrolled in training programmes, including clinical coding and the New GP Receptionist course, ensuring the team continued to build skills aligned with evolving service needs and patient care standards.

In 2025, Dovecot Surgery participated in several clinical research studies and public health initiatives aimed at improving patient care, supporting early diagnosis, and promoting healthier lifestyles. The practice collaborated with research and pharmacy teams, including FutureMeds and AstraZeneca’s Interface Clinical Services, to trial new treatments for chronic obstructive pulmonary disease (COPD) and to review asthma and COPD medications. A review of patient records identified 47 individuals who were eligible to take part.

The “Are You Taking the Pee?” campaign encouraged patients with conditions such as diabetes and high blood pressure to have a simple urine test to check for early signs of kidney disease. The campaign aimed to see whether displaying clear and visible information, such as posters and leaflets, around the practice would encourage more people to participate. A baseline report was completed before displaying materials throughout the practice for a 3-month period. The campaign concluded on 23 October 2025, and leaders told us they were awaiting final results to assess its effectiveness.

NHS Health Checks were also offered to assess patients’ risk of heart disease, stroke, diabetes, and kidney problems, supporting early intervention and promoting healthy lifestyle choices. Since 2024, the practice had improved its approach by calling patients instead of texting, offering health checks during other appointments, and reviewing progress monthly. These changes had a clear impact, health check invitations increased to 152 so far this year (up from 62 last year), and completed checks rose from 20 to 122. This showed clear progress in helping more patients access early health assessments.

The practice participated in studies for patients with kidney disease and those with a liver condition called MASH (Metabolic dysfunction–Associated Steatohepatitis). MASH is caused by fat build-up in the liver and is often linked to being overweight or having diabetes or high cholesterol. These studies aimed to test new treatments to protect kidney and liver health. A total of 22 patients were invited to take part. Leaders told us they did not receive individual trial results, but by participating, the practice helped provide patients with access to research that may benefit their care in the future and support wider medical progress.

Through these initiatives, the practice promoted innovation, evidence-based care, and continuous improvement for the benefit of its patients and the wider community.