Updated 4 August 2025
Date of Assessment: 22 September to 25 September 2025
Emsworth Medical Practice is a GP practice and delivers service to approximately 15,500 under a contract held with NHS England. The National General Practice Profiles states the service has a higher-than-average number of patients aged over 60. Information published by the Office for Health Improvement and Disparities shows deprivation in the service’s population group is in the 9th decile (9 out of 10). The lower the decile, the more deprived the population is relative to others.
This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
This was a comprehensive assessment, covering all key questions, due to the service having moved location and had not yet been inspected.
The premises were clean, well maintained, and most on-site risks were being managed effectively. Staff understood and managed risks to people, and equipment such as fire extinguishers and electrical appliances had been recently tested and were up to date. However, fire safety procedures were not yet fully embedded in day-to-day practice. The service was unable to provide evidence that staff had received fire marshal training or taken part in recent fire drills.
There was also a lack of clarity within the leadership team about whether certain health and safety responsibilities sat with the service or the landlord (NHS Property Services), which created gaps in oversight.
Staff recruitment files did not meet the full requirements of Schedule 3 of the Health and Social Care Act 2008. The service was unable to demonstrate professional registration checks had been completed before employing some clinical staff. Oversight of mandatory training was not effective, and the service could not confirm how frequently training compliance was reviewed or who was responsible for monitoring it.
Whilst people were involved in assessments of their needs, and staff supported them to understand their care and treatment, the service was not following national guidance in relation to monitoring long-term conditions. While no evidence of harm was found, this indicated recall systems were not fully effective. The service took prompt action to improve this during the inspection. Staff did work collaboratively with other agencies to support effective transitions of care.
There were some informal learning opportunities in place, such as case-based discussions, group reflection sessions and teaching from external speakers. However, formal oversight for learners and staff in training roles not available. There were no records to show supervision or support for these groups. Prescribing audits for non-medical prescribers, such as Advanced Nurse Practitioners, were not being carried out.
The service did not have a process to ensure staff were properly supervised for their roles. While yearly appraisals were taking place, there was no formal system of ongoing clinical supervision.
Governance systems were not fully effective. There was uncertainty within the leadership team about certain health and safety responsibilities, and there was insufficient oversight of recruitment checks, supervision processes, mandatory training compliance, and prescribing audits. Staff files did not consistently demonstrate that required checks had been completed.
There were informal learning and reflection opportunities, but the service did not have a process to support trainees and staff in development roles.
However, staff were compassionate, respectful and treated people as individuals. People valued the continuity of care provided by having a named GP. Staff protected people’s dignity and supported them to understand their care and treatment.
People were involved in decisions about their care and had opportunities to provide feedback. The service provided information in a way people could understand.
People were confident the service took their feedback seriously, and staff worked with other agencies to help ensure smooth transitions between services. The service worked to reduce barriers to access and supported people to be involved in planning their ongoing care.
Leaders were generally visible and supportive, although some staff told us communication and visibility were not always consistent. Staff understood their roles and responsibilities and felt able to raise concerns.
Leaders demonstrated openness to learning and improvement, and the service took prompt action during the inspection to address concerns in long-term condition monitoring.
We found one breach of the legal regulation relating to good governance. We have asked the service for an action plan in response to the concerns found at this assessment.