Swallowfield Medical Practice

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 provider did not have robust systems and processes in place to ensure effective oversight and governance of key areas of the service. In particular, there were gaps in the management and monitoring of risks relating to the dispensary and prescription security.These issues indicated that risks were not always proactively identified, assessed, or mitigated, and that governance arrangements were not operating effectively.

The key question has been rated as Requires Improvement and the service is in breach of regulation in relation Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (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. The leaders had an understanding of the challenges and the needs of people and their communities.

Peoples’ feedback was actively sought and improvements made where possible. For example, we saw an action plan had been developed following the 2025 National GP Patient Survey results, aimed at improving patient experience and reducing wait times for appointments.

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.

However, some staff told us leaders in the practice were not always approachable. This feedback was shared with the practice, who took this on board and recognised the need to make improvements. Leaders demonstrated a willingness to reflect and commit to work towards being more visible and accessible to staff.

We noted feedback from patients regarding the leaders within the practice, was consistently positive.

We saw the leadership team worked with other practice in the primary care network and were engaged in the development of primary care services within the local area.

The practice had established Freedom to Speak up arrangements internally. However, the staff did not have access to an external Freedom to Speak Up Guardian. This was promptly addressed by the practice following the site visit.

All of the staff we spoke with and received feedback from were aware of how to raise concerns.

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. We saw senior leaders had addressed concerns related to discrimination.

Staff had completed equality, diversity and inclusion training and provided examples of tackling inequalities during the assessment.

Staff had clear responsibilities, roles and systems of accountability. Lead roles were shared across the GP partners to ensure shared accountability and resilience.

We found areas where governance arrangements required strengthening, particularly in relation to the oversight of systems and processes supporting the management of the dispensary. Whilst some arrangements were in place, these were not consistently effective in identifying, monitoring, and mitigating risks.

We found gaps in oversight across key areas of dispensary management, including access arrangements, the handling and tracking of prescription stationery, and the effectiveness of prescription stock control and audit processes. We also found that governance arrangements for certain higher-risk medicines required improvement to ensure alignment with expected standards.

These issues indicated risks were not always proactively identified or escalated, and governance systems had not been sufficiently effective. However, the risks identified had not resulted in evidence of immediate harm to patients at the time of assessment. The concerns were therefore assessed as relating primarily to governance and system weaknesses, with the potential to impact patient safety if not addressed.

We found leaders were responsive to the findings. They engaged with the assessment process and demonstrated willingness to take action and make necessary improvements.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

The provider worked with one other practice within their Primary Care Network (PCN) to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services.

The practice was supported by a Patient Participation Group (PPG) which was made up of 6 members. We spoke with some PPG members who were positive about the practice. The PPG and the practice independently shared how they valued their collaborative working and partnership.
As part of the PCN, the practice supported access to seated exercise sessions delivered locally at a community leisure centre, which have proven popular with patients and well attended. This initiative promoted patient wellbeing, supported physical activity in a safe and accessible way, and strengthened links with local community services.

The service focused on continuous learning, innovation and improvement across the organisation and local system. The provider actively contributed to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services. This focused on the appointment system and appointment wait times. All staff were encouraged to put forward and test out new ways of working. We saw evidence of a range of audits, pilots and quality improvement projects.

For example, we noted a recent improvement activity, where in a significant case review identified a patient safety incident involving methotrexate, highlighting variation in clinical practice and gaps in communication. In response, the practice implemented standardised guidance, strengthened documentation and safety checks, and improved communication with patients, carers, and care settings. Systems were also enhanced to ensure regular blood monitoring prior to repeat prescribing and to support safer, more consistent prescribing in line with best practice.