Updated 23 June 2025
Date of Assessment: 28 July 2025 to 3 September 2025.
Ravenscroft Medical Centre is a GP practice and delivers services to approximately 5800 under a contract held with NHS England. The National General Practice Profiles states that the ethnic makeup of the practice area is 65% white, 15% Asian, 4% black, 4% mixed and 12% other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 7th decile (7 of 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. Scores were reached based on evidence found at this assessment.
This assessment focused on the areas of safe, effective, caring, responsive and well led. This is the first inspection of this service since its registration on 17 November 2022.
SAFE: The service had a learning culture and people could raise concerns. Managers investigated incidents, although some staff reported that the learning from incidents was not always shared. The facilities and equipment met the needs of people. They were clean and well-maintained and any risks mitigated. There were enough trained staff. Staff received training and regular appraisals. The risks to people had not always been identified and/or mitigated. Staff had not always managed medicines well. Consistency in the documented monitoring of people’s medicines was needed to make sure appropriate tests were carried out prior to a review or prescription being issued. Leaders acknowledged the safety concerns we identified during the assessment and took them very seriously. After the assessment, the provider informed us of actions they had taken to strengthen systems and processes. We will review these at our next assessment.
EFFECTIVE: People were mostly involved in decisions about their care, however, there were shortfalls in monitoring people with long term conditions. Care was based on latest evidence and good practice, however guidance was not always being followed. Staff worked with agencies involved in people’s care for the best outcomes and smooth transitions when moving services.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were mostly involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident that it would be acted on. Access was being improved. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback.
WELL-LED: There was a shared vision and culture based on listening and learning. Leaders were visible and supportive. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Processes, and systems to support good governance were in place but not fully embedded into practice. The leaders had not ensured that staff always followed prescribing policies and evidence-based guidelines. Since our assessment we have received evidence of changes made in relation to governance and management of risks. We will review these changes at the next assessment to see if they are effective and have become embedded into practice.
At this assessment, our clinical records reviews indicated that people with long term conditions and those on high-risk medicines were not followed up in line with guidelines and recommendations. We found that robust systems to deliver safe care and treatment were not always in place and gaps were identified in oversight of documented monitoring, in particular, medicines management, prescribing and recall processes.