Norwood 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 lookedfor evidence that the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last inspection, 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.

Leaders ensured there was a shared vision, strategy and culture that staff in all areas knew, understood and supported. They demonstrated a positive and compassionate listening culture that focused on learning and development. Staff described good teamwork and a service that was clear on its function to work in the interests of patients and provide the best patient experience they could.

Regular meetings were held for clinical and non-clinical staff. Members of the team told us that communication was good, and they felt included in decisions about the service. The culture of the service was based on transparency, inclusion and engagement. The provider understood the challenges and needs of people and their communities and was working with partner agencies to support people effectively.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There were clear arrangements for governance, management and accountability. A clear management structure was in place with designated staff members who acted as leads for clinical and non-clinical areas. The provider had established governance processes in relation to the quality statements we reviewed during this assessment, which were appropriate for the service.

Staff roles, responsibilities and lines of accountability were clear. Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. The service used digital services securely. We saw how information about risk, performance and outcomes were monitored and how change was discussed and implemented following feedback from people who used the service, staff and relevant stakeholders. Performance issues were escalated through appropriate structures and processes. Staff appraisals were used to manage staff performance. The management team used data to monitor and improve performance. For example, practice meetings were held, and discussions took place about performance and operational pressures. Clinical audit results were discussed in weekly clinical meetings to share learning and agree actions. A number of clinical audits were shared with CQC during the assessment showing that patient outcomes were closely monitored and results shared with the team.

Staff were aware of data or notifications that needed to be submitted to external organisations as required.Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. The practice used digital services securely and effectively. There were arrangements in place for the availability, integrity and confidentiality of data and records. Staff took patient confidentiality and information security seriously.

The provider understood their duty to collaborate and work in partnership, so services worked easily for people. They shared information and learning with partners and collaborated for improvement. Staff and leaders, we spoke with were open and transparent, and they collaborated with all relevant external stakeholders and agencies.

The provider sought feedback from patients and reviewed external sources of feedback such as the National GP Patient Survey 2026 and the NHS Friends and Family Test and took action to address any shortfalls identified. Leaders encouraged staff to speak up with ideas for improvement during regular clinical and non-clinical meetings. There were processes to ensure that learning was shared when there were incidents and action was taken to improve the service and prevent a reoccurrence.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.