Limestone 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 has been changed to Outstanding.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The leadership, governance and culture within the practice were used effectively to drive and improve the delivery of high-quality, person-centred care.

The service had a clear vision, strategy and positive culture, which focused on delivering high-quality, person‑centred and integrated care in a safe, responsive and courteous manner. Staff were able to describe shared values that supported this vision and guided their day‑to‑day practice.

Leaders demonstrated a positive, compassionate and listening culture and equality and diversity was actively promoted. The provider demonstrated an understanding of the challenges and evolving needs of the local population. Staff reported a positive experience of working at the practice. They described strong teamwork and a shared commitment to delivering high-quality, patient-centred care.

The practice also demonstrated a clear and ambitious direction centred on equitable neighbourhood care. Leaders developed a targeted approach for a deprived, diverse, and mobile Core20PLUS (which focuses on the most deprived 20% of the population) , including migrants, asylum seekers, and individuals experiencing language barriers, digital exclusion, and complex social needs. This insight informed service design, including multi-channel (tailored ways of access), non-digital pathways, digital inclusion support, migrant outreach, community pharmacy prescribing, cardiovascular prevention, and strengthened safeguarding oversight. Leaders also recognised the impact of the physical environment on patient experience, including issues with premises, signage, and navigation, and addressed these through a system-focused approach to risk management and partnership working.

The practice had a realistic strategy and supporting business plans to achieve sustainability. The leadership team were committed to working collaboratively with their Primary Care Network (PCN) and the local community to educate and achieve positive outcomes for their patient population.

The practice had appropriate systems, processes and information in place to monitor and manage current and future performance. Performance data used by the practice was accurate, valid, reliable and timely, which enabled leaders to identify areas for improvement and maintain oversight of the quality of care delivered.

Leaders demonstrated a clear understanding of the relationship between environmental responsibility and population health, particularly for communities affected by deprivation and long‑term conditions. Sustainability was actively considered as part of the practice’s strategic planning, recognising its potential impact on health outcomes and health inequalities. An action plan had been developed to review, monitor and strengthen the practice’s commitment to environmental sustainability and a wider responsibility for supporting population health and future service sustainability.

The service was led by exceptionally inclusive leaders at all levels who demonstrated a strong understanding of the context in which care, treatment and support were delivered. They consistently embodied the culture and values of the organisation and workforce, and led with integrity, openness and transparency. Leaders had the appropriate skills, knowledge, experience and credibility to deliver effective leadership.

Leaders demonstrated a clear understanding of population need and proactively identified workforce and access risks. They designed sustainable systems and worked in partnership to reduce avoidable administrative demand, while embedding robust training, governance processes, and support for staff development and service resilience. A shared sense of purpose was evident, with leaders actively modelling the values of the practice and the wider organisation.

The practice had continued to strengthen leadership capacity beyond the core partnership team through structured support and development opportunities. Leaders recognised the challenges faced by staff delivering care to a deprived, diverse and high-need population, including pressures relating to high demand, language barriers, digital exclusion and complex patient navigation. These challenges were actively addressed through supportive leadership and system improvements.

Staff were encouraged to raise concerns, provide feedback and contribute to service improvement. There was a strong commitment to learning and development, reflected in the practice’s status as an accredited training practice for GP trainees and evidence of ongoing professional progression, such as support for a practice nurse to undertake an independent prescribing qualification.

Staff reported that leaders were approachable, responsive and consistently demonstrated the practice values in their day-to-day interactions. The leadership team worked collaboratively with other practices within the Primary Care Network (PCN) and with wider local partners. Leaders were actively engaged in the development of primary care services across the locality, demonstrating a clear commitment to system working and continuous improvement.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had clear policies and procedures accessible to all staff, for example, there was a whistleblowing, equality and diversity and duty of candour policy in place and a nominated freedom to speak up guardian to support staff if they wanted to raise an issue. Leaders told us they encouraged the reporting of incidents to identify ways in which the practice could continually improve.

The service strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

Policies and procedures were in place to support the safe recruitment of staff. These included policies on recruitment, equality and diversity, bullying and harassment, and grievance procedures, which provided a clear framework for fair and respectful workplace practices.

All staff had access to regular appraisals, one‑to‑one meetings, coaching, mentoring and, where applicable, revalidation. An induction process was in place for newly appointed staff, and staff told us they felt well supported and able to seek advice when needed.

Staff reported they were encouraged to develop within their roles, and that appropriate training and development opportunities were available. Feedback from staff demonstrated a positive, no‑blame culture, where learning and improvement were encouraged and staff felt safe to raise concerns.

Leaders demonstrated an understanding of the pressures affecting front line staff and took appropriate action to address these. For example, the General Practice Improvement Programme (GPIP) identified key workforce challenges, including role strain, exposure to challenging interactions and risks to service sustainability. In response, the practice implemented a range of supportive measures, including de-escalation training, communication tools, improved role clarity, cross-cover arrangements and the development of a skills matrix.

In addition, the practice utilised governance and escalation processes to raise operational estates risks impacting both patient and staff safety. These concerns were escalated to system partners with clear actions identified, demonstrating a proactive and structured approach to risk management and supporting staff wellbeing and psychological safety within a safe and inclusive working environment.

The service had clear responsibilities, roles, systems of accountability and effective governance arrangements in place. These were used to manage and deliver good quality, sustainable care, treatment and support. Leaders acted on information about risk, performance and outcomes and shared this securely and appropriately with relevant partners.

Leaders and managers supported staff effectively, and all staff we spoke with were clear about their individual roles and responsibilities. Managers met with staff regularly to undertake appraisals and performance reviews, which supported professional development and accountability.

The provider had established governance processes that were appropriate to the size and complexity of the service. Staff had access to all required policies and procedures and demonstrated an understanding of how these supported safe and effective practice. Managers held regular practice meetings with staff, during which clinical concerns, incidents and emerging risks were discussed. Actions arising from these meetings were clearly recorded, monitored and shared with staff.

There were clear oversight mechanisms in place that supported consistency, strong governance frameworks and organisational stability. Governance arrangements were well embedded into the day‑to‑day running of the service and underpinned by a clear framework of accountability. This enabled leaders to monitor performance and risk effectively and supported the delivery of quality audits and continuous improvement.

Audits reviewed demonstrated that governance and performance management arrangements were proactively monitored and reflected best practice. Where improvements were identified, actions were taken to strengthen service delivery.

The service promoted an open and transparent culture where safety was a priority. Systems were in place to record and investigate incidents and manage complaints. Learning from incidents and complaints was shared and led to changes that improved care and outcomes for patients.

Leaders and managers encouraged positive accountability and sustainable improvement across the organisation. Patient confidentiality and information security were well understood and taken seriously by staff.

The service demonstrated exceptional system leadership and partnership working to deliver seamless, person‑centred care pathways that were shaped by best practice and people’s informed preferences. Leaders worked across the neighbourhood system to design and embed new models of care, including migrant health support, pharmacy prescribing, social prescribing, parent infant emotional wellbeing (PIEW), palliative care and veteran pathways. This improved access to GP appointments and enabled patients to receive timely care from the right professional.

Leaders took a proactive and strategic approach to addressing equity across their local population. This was particularly evident in the practice’s work to support migrant and asylum‑seeking patients. Leaders recognised that the practice and surrounding area served a significantly higher proportion of migrants and asylum seekers and that existing support arrangements and care pathways were insufficient to meet the complexity of need. Rather than adapting existing services in isolation, the practice took a role in researching, influencing and co‑designing solutions at system level. The practice actively sought and adapted successful initiatives from other areas to develop a Dudley‑based model that addressed health inequalities in a sustainable and coordinated way. Through effective collaboration the model provided structured, compassionate support to help patients navigate healthcare systems, address language barriers, and manage immigration‑related stress.

The impact of this work was demonstrable with the practice reporting a reduction in migrant‑related GP consultations of approximately one‑third, a marked reduction in demand for interpreter services, and increased clinical appointment capacity. This enabled clinicians to focus more effectively on complex care needs while improving access, experience and outcomes for patients who previously faced the barriers to healthcare.

Leaders, managers and staff consistently strived for excellence through shared learning, innovation and partnership working. For example, the practice played an active and influential role in the Parent‑Infant Emotional Wellbeing (PIEW) programme, working across organisations to provide early relational and emotional support for families. This preventative, integrated model demonstrated a commitment to improving long‑term outcomes through early intervention and system collaboration.

Overall, the practice demonstrated a strong commitment to reducing health inequalities and improving population health outcomes through collaborative, and consistent person‑centred care. Leaders showed a clear understanding of their community’s needs and took proactive action to support improved access, experience and outcomes for groups most at risk of inequality.

There was an established Patient Participation Group (PPG). We spoke with 2 members who shared positive examples of meaningful involvement, including supporting health promotion initiatives and gathering patient surveys feedback. The practice used feedback to inform service development and drive improvements.

The practice was veteran‑accredited and had effective processes in place to proactively identify veterans and ensure they were appropriately supported. This included signposting to specialist services and access to priority referral pathways where required.

In addition, the practice demonstrated a strong commitment to compassionate, community‑focused care through collaboration with palliative care services. This included hosting a community awareness stand to improve understanding and access to end‑of‑life support, as well as undertaking fundraising activities to directly support palliative care provision.

In addition, the provider demonstrated collaboration within the Primary Care Network (PCN) by working with other practices to deliver extended access services.

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 contribute to safe and effective practice.

The leadership team held regular staff meetings to share learning from incidents and complaints and monitor the quality of the services provided. They also worked collaboratively with stakeholders to improve the experience of people using the service and to support the wider needs of the local community.

The practice had a comprehensive quality improvement programme in place that actively informed service development. This included regular and systematic monitoring of access to ensure responsiveness to demand. Quality improvement activity was informed by data, feedback and learning and used to shape ongoing service delivery.

The practice operated as an accredited training practice and demonstrated a strong commitment to workforce development and future sustainability. Clinical staff were actively supported to develop advanced skills, including a practice nurse undertaking independent prescribing training and pharmacists training as prescribers under GP supervision. In addition, the practice nurse provided mentorship to a nurse associate within the Primary Care Network (PCN).

At the time of our assessment the practice was piloting the use of artificial intelligence to help understand different needs within the community and help analyse different patient groups so they can plan care better.The practice was also leading work within the Primary Care Network (PCN) to develop a fully functioning neighbourhood health model. This model aimed to integrate existing initiatives into a coherent structure, deliver measurable improvements in both patient outcomes and service demand, align with Integrated Care Board (ICB) and NHS England priorities, and be collectively owned by the PCN. A business case had been submitted to the ICB to support this development.