Abbey 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 the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same. However, we found a breach of regulations in good governance. Systems and processes to underpin the running of the service were not effective.

This service scored 71 (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 vision, strategy and culture, work was ongoing to develop the strategy into a formal plan to enable the service to show ongoing monitoring and progress with completing tasks. Leaders understood the challenges and the needs of people and their communities. It was evident that steps were being taken to start planning ahead and develop a strategy for service provision in the future.

Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

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.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance processes in relation to the quality statements we reviewed during this assessment, were not consistently effective. Systems and processes were not consistently effective, for example in relation to ensuring all required checks had been carried out prior to staff starting to work at the service and those related to staff training; and those related to infection control and health and safety to ensure risk was mitigated as far as practicably possible. Records which supported the good governance processes were not completed fully to enable the service to assure themselves that systems were operating effectively and safely.

During our site visit the provider took action when needed to address concerns found. The provider had commenced work on their governance systems prior to the inspection, they were aware that improvements were needed to ensure audits, policies and action plans were completed fully to be able to assure themselves that the service was operating safely.

GP partners had recently put in place an action log (dated 5 June to 3 July 2026) to monitor risks and actions. This recorded the replacement of chairs and flooring throughout the practices but did not detail infection prevention and control or health and safety risks we identified during our onsite visit. It did include staffing and other areas of business. For example, finances, access and staff/service user communication. The service was developing a key performance indicator board to support this work, which was due to be introduced in September 2026; and then be developed into a 3 year business plan for the period September 2026 to August 2029. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews.

At the branch site we saw that people’s paper records were stored in open shelving therefore accessible, the service was unable to confirm whether the external cleaning company had signed confidentiality agreements. However, staff who provided care and treatment took confidentiality and information security seriously, which included verifying people’s identity during remote consultations.

Staff could access all required policies and procedures, which were kept up to date and reflected latest guidance. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service. Leaders recorded any actions that arose from these meetings and shared these with staff. Staff submitted data and notifications to external agencies as required.

The service had 4 trainee GPs and had been able to employ previous trainees when there were vacancies, which assisted in meeting staffing needs and supported sustainability of care and treatment.

All employment contracts had been reviewed by an external consultant to ensure they were compliant with employment law. All staff had received updated copies of their employment contracts.

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.