Archived: Central 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 Requires Improvement. At this assessment, the rating has changed to Good.

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 practice 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.

At our last inspection we found:

• Although the practice was using national survey data to consider changes and improvements, there were no additional surveys or methods of patient feedback being utilised.
• There was no Patient Participation Group (PPG), as had been found at the time of our earlier inspection in 2016.
• Staff surveys had ceased in 2019, however, the practice had plans to re-implement these.

At this assessment we found:

• The practice acted on complaints and significant events. Where appropriate it implemented changes in procedures and policies to improve or prevent recurrence of issues.
• There was an active PPG which gave the practice feedback on issues of concern to the patient population.
• We saw the findings of the 2025 staff survey, which the practice told us would in future be run annually. The practice had used the findings to plan for changes, including a rewards and benefits package to recognise staff contributions and commitment.

All staff were encouraged to contribute to the development of the practice vision and strategy, which was kept under review.

The practice 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.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff described leaders taking staff well-being very seriously. They referred to managers as all having open door policies and they felt able to go to them for support at any time, without hesitation. Staff also told us leaders modelled the values of the practice. 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 practice fostered a positive culture where people felt they could speak up and their voice would be heard.

Leaders acted with openness, honesty, and transparency with staff.

The practice had established Freedom to Speak up policies and worked with other practices in the primary care network to provide independent freedom to speak up support where staff felt unable to raise concerns with senior managers within the practice. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard.

Leaders acted with openness, honesty, and transparency with staff.

The practice had established Freedom to Speak up policies and worked with other practices in the primary care network to provide independent freedom to speak up support where staff felt unable to raise concerns with senior managers within the practice. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The practice 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

At our last inspection we found:

• There was a lack of governance, including no clear audits of significant events, safeguarding, complaints, patient feedback and phone access data. However, the practice could demonstrate that it had recognised those issues and was taking action to implement audit systems and processes.
• There was a lack of assurance systems in place, for example the IPC audits were undated and had not been reviewed or appropriately acted upon.
• Following the inspection the practice had taken action to address these issues.

At this assessment we found:

• It had implemented a programme of audit to drive performance across the practice.
• The practice had a programme for IPC audits and acted upon the findings.

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. Staff could access all required policies and procedures. The practice recorded any actions arising from staff and clinical meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network to share best practice, training opportunities and quality improvement projects. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The practice 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.

At our last inspection we found there was little evidence of proactive learning or of continuous improvement through audit cycles or innovation.

At this assessment we found the practice had a proactive approach to learning and continuous improvement. For example, the practice was participating in a programme to support patients who were part of the special assistance programme. Patients in this programme made heavy demands of GP services, often requestion multiple appointments each week. Patients in the special assistance programme were allocated a patient advisor who was in regular contact with them. The patient advisor triaged appointment requests avoiding the booking of unnecessary appointments.

The practice had implemented a robust programme of clinical audits which it also used to drive improvement.