Medwyn 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 practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. There were consistent examples of how an inclusive, supportive, and collaborative leadership approach had driven improvements in safety, sustainability, care integration, meeting patient’s needs and inequalities for staff and patients who used services.

Governance and management systems enabled leaders to identify and act on information about risks, performance, and outcomes. Leaders demonstrated a commitment to continuous improvement, using feedback from patients using the practice, families, and staff to inform service development.

At our last inspection, we rated this key question as Outstanding. At this inspection, the rating remains the same.

This service scored 93 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a very clear and well embedded shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. Leaders demonstrated the importance of staff wellbeing to support them in maintaining good outcomes for patients. Leaders invested in learning and development for all staff and developed tools to assist staff to achieve best practice.

There was a clear mission statement ‘A committed professional and respected team bound by mutual values providing high quality and innovative care to the whole community.’ Staff were positive about the culture within the practice and described it as open and transparent.

Values were actively integrated into daily practice, establishing an open and respectful culture. Staff told us they felt valued, motivated, included, and supported because leaders listened and recognised their work. Managers were approachable and encouraged staff speaking up in relation to ideas or areas of concerns. There was regular supervision and meetings, which allowed staff to reflect, and learn collaboratively.

The practice had exceptionally 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 always did so with integrity, openness, and honesty.

Staff told us leaders in the practice were approachable and responded to any concerns raised. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

Leaders actively engaged with patients, staff, and partner organisations to gather feedback on their management and communication, and they took meaningful action in response. During the inspection, they clearly demonstrated how they had implemented positive changes wherever possible. Feedback received, both directly by the practice and through the CQC from patients, and staff was consistently highly positive.

Staff we spoke with told us leaders were approachable and responded to any concerns raised. There were regular management and staff meetings to ensure all staff members were aware of changes to service delivery.

The practice had an equality and diversity policy and promoted equity to all patients. Staff were able to request adjustments to working at any time but were reminded during appraisals, and in supervision meetings. Examples included, flexible working hours and rotas to support family or caring responsibilities, home working arrangements where possible, and sit–stand desks provided for musculoskeletal needs. Adjustments could also be requested for cultural and faith needs, such as flexibility for prayer times or dietary requirements during practice events.

Staff told us that leaders cared about their wellbeing and provided initiatives such as a walking club, Pilates, Friday socials, and a Zumba classes.

Staff were given the opportunity to provide anonymous feedback on culture and values. Feedback received showed that staff wanted to feel more valued and recognised. In response the leaders revised the existing approach of rewarding staff through Going the Extra Mile scheme and created a recognition of long service and team achievements. Feedback from staff also highlighted an increase in workload and long hours especially among reception staff. Leaders reviewed workflows and redesigned triage/care navigation to reduced pressure.

The practice fostered a positive culture where patients 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 practice had an open culture where staff felt confident to speak up if they had concerns or ideas for improvement. Staff told us they were listened to and felt safe raising issues without fear of negative consequences. Leaders promoted honesty and transparency, encouraging staff to share concerns early so they could be addressed quickly. There were clear policies in place, and staff knew how to access them if they wanted to raise a concern formally. Regular team meetings and supervision sessions gave further opportunities for staff to talk openly about their experiences.

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

Staff we spoke with told us about career development and opportunities for learning. For example, reception staff progressing to management roles, with leadership training supported for internal candidates.

The practice had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment, and support. They acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. GPs were each assigned clinical areas to oversee, and staff informed us that they knew who to contact if they had any queries or concerns. Staff we spoke with told us the leaders had an “open-door” policy and were always responsive and available to provide support. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

Strategic progress was formally governed by the Practice Development Plan Strategy 2025–2028. This plan was regularly updated following partnership meetings, Multi-Disciplinary Team (MDT) meetings, and various strategic sessions. A core component of this oversight was the review of risks and potential obstacles at each meeting, with all resulting actions formally documented and monitored within the plan. To ensure continued operational and cultural alignment, the mission statement, values, and vision were a standing agenda item for strategic meetings, meaning they remain relevant, and representative of the current practice culture. Progress was consistently cross-referenced with the 12-Month Business Plan and validated against external quality benchmarks, including the Quality and Outcomes Framework (QOF), national patient survey data, and CQC quality standards. The strategy was also monitored against wider priorities, including the NHS 10-Year Plan and Core20PLUS5. (Core20PLUS5 is a national NHS England approach to inform action to reduce healthcare inequalities at both national and system level).

The practice had plans in place to promote sustainability and looked at ways of reducing its carbon footprint. The Practice Development Plan Strategy 2025–2028 included: developing a green Medwyn strategy, reducing use of printing and, encourage staff to use public transport as well as developing a cycle to work scheme.

There was a robust system and process in place to ensure mandatory checks were carried out within the relevant timescales. For example, health and safety risk assessments and maintenance of equipment, such as fire extinguisher checks and calibration of clinical equipment.

There were effective processes in place for staff recruitment, and we saw evidence of appropriate checks being carried out for new staff. Staff had completed all mandatory training and practice leaders had excellent oversight of what had been completed.

The practice clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for patients. They always shared information and learning with partners and collaborated for improvement.

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

The practice hosted a sixth form careers event for the PCN, giving students the opportunity to hear talks and gain experience if they were interested in pursuing a career in medicine, nursing, or allied health. Leaders told this event inspired the next generation of healthcare professionals and strengthened links with local schools and colleges.

The practice had established a Medwyn Carers Network following direct feedback from patients registered as carers at the practice. The first event took place in September 2025 and over 40 carers and 5 external support organisations, alongside key practice staff and the Carers Champion attended. Due to the overwhelmingly positive feedback, carers were now helping to steer the network's development, resulting in a commitment from the practice to host a regular monthly dementia carers’ support group.

The practice hosted meetings with local community pharmacists following the launch of Pharmacy First. They also hosted presentations from Musculoskeletal (MSK) First Contact Physiotherapists and learning sessions from a psychiatry colleague as well as hosting them in the practice to provide a safe, familiar environment for less emotionally stable patients, ensuring they felt at ease during clinical assessments.

The practice also provided a meeting space for community groups such as MASH (Men Alone Self Help) and the Ageing Well group.

Health campaigns were promoted to patients through newsletters (electronic and paper) and social media channels including Facebook.

The practice collaborated with DHC Livewell social prescribing service who could proactively support patients with menopause, new cancer diagnoses, and through talking therapies for perinatal mental health (Evolve).

The practice 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.

The practice used learning from significant events and complaints to continually improve the service they provided, and changes were made within the practice if needed.

We saw examples where staff had requested and been offered the opportunity to progress in their roles and/or add to their skills. These included clinical and non-clinical roles.

We saw evidence of a range of audits and quality improvement projects. Projects were designed to improved performance, outcomes, and patient experience. For example, triage and care navigation redesign, heart failure medicines optimisation and urgent suspected cancer referral safety-netting. All staff were encouraged to put forward and test out new ways of working.