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Upton Road Surgery Requires improvement

This service was previously registered at a different address - see old profile

We are carrying out a review of quality at Upton Road Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 1 October 2019

This practice is rated as requires improvement overall. (Previous rating 12 December 2018 – Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Upton Road Surgery on 12 December 2018. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. Warning notices were served in relation to breaches identified under Regulation 12 Safe care and treatment and Regulation 17 Good governance. The practice was placed into special measures for a period of six months.

We completed an announced focussed inspection on 9 May 2019 to check on the areas identified in the warning notices and to see if sufficient improvements had been made regarding these. Improvements were evident, and the practice had acted to comply with the legal requirements.

The full comprehensive report from the December 2018 inspection and the focussed report for the May 2019 can be found by selecting the ‘all reports’ link for Upton Road Surgery on our website.

This announced comprehensive inspection on 8 August 2019 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall. We rated all population groups as requires improvement because of the issues identified in the effective and responsive domains.

We rated safe and caring as good because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated effective as requires improvement because:

  • Care for people with long term conditions needed improvement.
  • Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets.
  • The operation of the ‘failsafe system’ to check on outstanding cytology results needed improvement.

We rated responsive as requires improvement because:

  • Patients satisfaction in relation to access care and treatment in a timely way in the 2019 National GP Survey had significantly decreased in comparison to the 2018 National GP Survey results.

We rated well led as requires improvement because:

  • The practice had implemented systems that provided leadership and governance which had promoted a positive culture to support inclusive patient centred care. However, systems and process to review clinical and quality monitoring were not fully established.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve patient satisfaction (based on 2019 national GP survey results).

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas




Requires improvement




Requires improvement


Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement