- GP practice
Abbeyview Surgery
We served a warning notice against Abbeyview Surgery on 9 October 2025 under safe care and treatment and poor governance systems, placing people at risk of harm
Assessment report published 1 December 2025
Contents
Ratings
Our view of the service
Date of Assessment: 4 August 2025 to 29 September 2025. The Abbeyview Surgery is a GP practice and delivers service to 9059 patients under a contract held with NHS England. The National General Practice Profiles states that the ethnicity of the practice population was 95.7% White, 1.34% Asian, 1.04% Black, 1.62% Mixed and 03% other ethnicity. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 7th decile (1 to 10). The lower the decile, the more deprived the practice 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 is this provider’s first assessment for this service and the rating is requires improvement.
We found a lack of oversight of systems and processes, including with significant events, complaints, risk assessments and of the environment.
Remote searches of the practice’s clinical systems also demonstrated a lack of oversight with multiples issues identified which did not assure us that patients were always safe.
We found a breach in regulation under safe care and treatment and as a result took enforcement action asking the practice to take appropriate actions within 3 months to meet the areas of improvement identified. We found all emergency medicines were not always available and where risk assessments were in place these did not give sufficient information around mitigation in place, patients at risk of lack of appropriate monitoring and review of medicines and poor management of blood pressure readings. We also found a breach in regulation under good governance and as a result took enforcement action asking the practice to take appropriate actions within 3 months to meet the areas of improvement identified. We found a lack of oversight of systems and processes to manage significant events, complaints, staff breaks, clinical and environmental risk assessments, in line with legislative requirements. Appropriate governance and management processes were not in place for managing and monitoring when patients have a raised blood pressure and a lack of assurance around accuracy of patient records.
The practice demonstrated they were keen to improve from the issues we identified and had already developed an approach to ensure more consistent outcomes for patients, staff, learning and culture.
The practice had proactively contacted us with their own action plan to address issues identified from our clinical searches and were working to ensure appropriate medicines reviews and monitoring was in place.
People's experience of this service
People were not always positive about the quality of their care and treatment. Recent results from the National GP Survey showed almost all areas were responded to as being below the national average. There was an active patient participation group (PPG) who represented the views of people using the service and they were positive of the practice’s engagement with them. Direct feedback we received from people who used the service highlighted that people found accessing the service difficult at times and did not feel care was always consistent.