Dr A Riaz and Mrs Shabana Riaz

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 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.
The practice mission statement was ‘To deliver responsive, evidence-based healthcare that is safe, effective, caring and inclusive. Where patients are placed at the centre of everything, embracing innovation, learning and collaboration to meet the changing needs of the population, while maintaining the highest standards of clinical excellence and governance’.
Staff spoken with told us the mission statement had been shared with them and kept under review. The practice vision was displayed in the waiting room which was ‘Caring for our community today, empowering healthier lives tomorrow’.
Leaders demonstrated a positive and compassionate listening culture. They described the culture of the service as open and engaging, which was reflective of what staff told us. They said they felt supported to raise any concerns which they knew would be listened to and acted on. All the staff we spoke with told us they enjoyed working at the practice and were very supportive of each other.

The service had inclusive leaders 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 told us leaders were approachable and responded to any concerns raised and modelled the values of the practice. 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.
 

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 in place and staff were aware of how to raise concerns. Staff could also access external arrangements through their Primary Care Network.
 

The service valued diversity in their workforce. They work 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 and staff had received training. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support a disabled staff member 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 acted on the best information about risk, performance and outcomes, and share this securely with others when appropriate.
Since the last inspection there had been changes in the partnership and registered manager, The practice’s registration with the Care Quality Commission needed to be updated to reflect the changes within the service. Leaders had recently taken action to address these requirements and acknowledged this should have been actioned sooner. The CQC current rating for the location was displayed on the website but not within the practice. Immediate action was taken to address this legal requirement.
Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service and took immediate action to address some of the shortfalls we identified in relation to providing safe services as part of this assessment.
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 also had access to a staff messaging group to share information. Staff took patient confidentiality and information security seriously.
 

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.
The service was part of Seisdon Primary Care Network (PCN), a group of 8 local practices that worked together offering extended access, flu and covid vaccination programmes.
The service worked with community healthcare services and had established meetings were in place to discuss the care of higher risk patients, including those at end of life.
Leaders told us they had good working relationships with colleagues in the Integrated Care Board (ICB). The ICB told us the practice engaged with them and were always happy to work with them and their PCN. No concerns about the practice were shared with us by the local Healthwatch team.
The practice had a Patient Participation Group (PPG) to represent the voice of the patients. Meetings were held approximately every 9 months with around 6-8 members attending alongside the practice management team and a GP. A representative told us they were trying to increase membership to the group to ensure it fully represented the patient population. They told us they had worked with the practice and the community to improve patient experiences. Examples shared included hedge trimming and improving the road surface to the practice. The local community had also assisted with snow clearing of the lane and practice car park last Winter. The PPG representative told us they regularly reviewed comments made on social media platforms and advised there were never any complaints made about the practice.
 

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, effective practice and research.
As part of the practice’s commitment to clinical excellence, patient safety, medicines optimisation, and continuous quality improvement, they had undertaken a programme of 5 clinical audits during 2025. The audits were designed to assess compliance with national guidance, identify opportunities for improvement, and implement changes that enhance patient outcomes and governance standards. Collectively, these audits resulted in improved compliance with national good practice and local prescribing guidance and evidenced continuous quality improvement and learning within the practice. Outcomes were discussed within the practice governance
e framework, and actions were implemented to ensure sustained improvement and patient safety.
Leaders told us due to long waiting lists they had upskilled a member of staff to provide a spirometry service to their patients to reduce the waiting time for people requiring this service.
The practice was a training practice for GP registrars and foundation doctors. Supervision and support arrangements were in place. The practice had signed up to National Institute for Health and Care Research, actively embedding clinical studies.