Moulton 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

The practice had a clear and well-communicated vision and strategy focused on delivering high-quality care and achieving positive outcomes for patients. Staff understood their individual roles and responsibilities, with clear lines of accountability across the service. Leadership was strong, with capable, compassionate, and inclusive leaders who maintained effective oversight of the practice’s operations. There was a culture of openness, honesty, and transparency, underpinned by the duty of candour. Both leaders and staff shared a common vision built on continuous learning, collaboration, and trust. Leaders were visible, approachable, and supportive, actively fostering staff development and professional growth. At our previous assessment, this key question was rated 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.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff consistently described the practice leaders as approachable and responsive, noting that any concerns raised were promptly addressed. The leadership team exemplified the practice’s core values through their actions and decision-making, fostering a positive and supportive work environment. They demonstrated strong experience, capability, and capacity to ensure the delivery of high-quality, person-centred care tailored to patients’ needs. Staff reported feeling genuinely valued for their contributions and were actively encouraged to pursue ongoing professional development opportunities. This highlights the leadership’s commitment to staff growth and empowerment. Furthermore, the leadership team maintained a collaborative approach by working closely with other practices within the Primary Care Network (PCN), sharing knowledge, best practices, and innovations.

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 with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

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

Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Practice leaders held clearly defined lead roles, which were further supported by administrators assigned to specific lead responsibilities within the practice. This structure made the governance framework transparent, allowing all staff to understand who was accountable for various areas. Staff were confident in their individual roles and responsibilities and could clearly explain the overall governance system. Regular appraisals and performance reviews were conducted for all staff, with thorough documentation and actionable development plans in place. The provider had established robust and detailed governance processes to maintain comprehensive oversight of all practice activities. Evidence showed that audits were routinely completed to ensure staff compliance with policies and procedures. Any identified areas for improvement were treated as learning opportunities to promote continuous practice-wide enhancement. The governance and oversight of the practice were strong, supported by clear, well-maintained documentation. Regular practice meetings were held to discuss clinical concerns and emerging risks, with thorough records kept and communication disseminated to ensure all staff remained informed and supported in delivering safe patient care. Additionally, staff demonstrated a strong commitment to always maintaining patient confidentiality and information security.

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 actively collaborated with other practices within their Primary Care Network (PCN) to deliver extended access services and flu vaccinations. To enhance coordination with community healthcare services, staff implemented adjustments that included establishing weekly multidisciplinary meetings focused on the care of patients at higher risk of hospital admission. These efforts improved communication and care planning, supporting better health outcomes for vulnerable patients through more integrated service delivery.

The service focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The service actively participated in regular meetings where people’s care and treatment needs were discussed to improve their outcomes. The service worked within a multi-disciplinary team to provide the right support for everyone. They made use of internal and external reviews of incidents and complaints where learning was shared and used to make improvements.