Bevan Medical Group 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 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 based on transparency, equity, equality, human rights and inclusion. Leaders understood the challenges within the local community, including the impact of deprivation and the population’s health needs, and used this insight to shape priorities such as improving immunisation uptake and supporting people to stop smoking.

Staff told us there was an open and honest culture within the practice. They felt confident to raise concerns without fear of retribution and believed that their views were listened to and valued. Staff also said that there was a clear vision for the future.

The service had inclusive leaders at all levels who understood the context in which they delivered care 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 in the practice was 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.

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, and staff told us they knew how to raise concerns if needed. Most staff who responded to the feedback questionnaire confirmed that they understood what whistleblowing was and how to report concerns.

During the assessment, we noted that the Freedom to Speak Up policy listed an incorrect guardian. Leaders told us the policy was updated immediately to reflect the correct information.

The service valued diversity within its workforce and worked towards an inclusive and fair culture by promoting equality and equity for staff.

Policies and procedures to support equality and diversity were in place, and leaders took steps to understand and respond to individual circumstances where appropriate.

The service had governance arrangements in place, although some areas required strengthening to provide full assurance around safety and oversight. A small number of documentation issues were identified, including insufficient detail in some medication reviews and occasions where required clinical forms, such as risk assessments or DNACPR documentation, were not recorded on the system. A small number of policies contained outdated or incorrect information, which was amended immediately.

Environmental and safety issues, such as the condition of the car park and the accessibility of emergency medicines, had not been captured through formal risk assessment. Leaders told us after the assessment they had begun obtaining quotes for the car park and had relocated emergency medicines and resuscitation equipment to reception areas.

Additional operational gaps included a medicines fridge that was not lockable at 1 site, interpreter services not being clearly signposted, and opening hours and out‑of‑hours information not consistently displayed. Care navigators had also received a lower level of safeguarding training than required for their role; however, since the assessment, leaders told us that training requirements had been updated, and staff were in the process of completing the correct level.

While some areas required improvement, staff were clear about their roles and responsibilities and told us they felt supported by managers. Regular appraisals and performance reviews were completed, and staff had access to policies and procedures. Governance structures were in place, with regular meetings held to review clinical issues, operational matters and emerging risks, with actions recorded and shared with staff.

Leaders acknowledged the areas for improvement and had begun taking steps to strengthen governance arrangements.

The service clearly understood its duty to collaborate and work in partnership. Leaders and staff shared information and learning with partners and worked closely with health, voluntary and community organisations. The practice played an active role in system‑wide initiatives to reduce inequalities and improve population health.

There was extensive collaboration across the local healthcare system. The practice participated in the Primary Care Network frailty service, working with the multidisciplinary team to deliver holistic assessments and coordinated care for severely frail housebound patients. The practice also contributed to the community diabetes service, holding regular multidisciplinary meetings with the hospital Diabetes Specialist Nurse to support early intervention and reduce the need for hospital‑led treatment.

The practice played an active role in wider public health and population‑level programmes. This included participation in the Deep End Immunisation Incentive and the CAREDEEP Cancer Care Coordinator pilot, both aimed at improving access and engagement among harder‑to‑reach groups. The practice also supported the local multi‑agency breastfeeding action plan, contributing to a collaborative public health response in an area with historically low breastfeeding rates.

Partnership working extended across sectors. The practice engaged in cross‑agency collaboration with the Department for Work and Pensions Patient Advice Service, which provided personalised employment support for people whose health affected their ability to work. This helped patients access reasonable adjustments, build confidence and secure new employment opportunities.

There was strong partnership activity within the local community. The Social Prescribing Link Worker worked closely with a wide network of voluntary and community organisations to coordinate tailored support for people experiencing complex social, financial and wellbeing‑related needs. The SPLW also worked with local businesses and charities to address social and digital inequalities, securing donations of food, toys, mobile phones, SIM cards and IT equipment for people in severe hardship, as well as organising and distributing Christmas hampers for isolated older adults. These partnerships enabled vulnerable people to access practical support, maintain social inclusion and overcome barriers to engagement with healthcare.

The practice also engaged with a local school and Family Hub service to support families experiencing challenges such as persistent absence, demonstrating proactive community partnership working beyond healthcare settings.

Overall, the service showed exceptional collaboration across health, social care, voluntary and community sectors. These partnerships enabled innovative, joined‑up approaches that improved access, reduced inequalities and supported better outcomes for local people.

The service supported continuous learning and improvement across the organisation. Staff told us they were encouraged to develop their skills and were well supported by leaders. As a training practice, there was a strong emphasis on professional growth, and 2 staff members were enrolled on the Aspiring Practice Manager programme. Staff also described a culture where they felt comfortable asking for advice and discussing how they wished to progress, and said they were offered training opportunities in response. A member of staff told us that managers routinely shared available study days, including diabetes updates, and supported them to attend to maintain up‑to‑date practice.

The practice undertook a range of quality improvement activities to support safe and effective care. This included full‑cycle audits and other monitoring exercises which were used to inform ongoing development and strengthen clinical practice.

Learning from complaints and significant events was reviewed and shared with the team. Recent learning included improvements to wound‑care documentation and the introduction of written care plans for people choosing to self‑manage their wounds at home, demonstrating how feedback was used to strengthen systems and practice.