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Inspection Summary

Overall summary & rating


Updated 28 June 2019

We decided to undertake an announced focused inspection of this service on 14 May 2019 following our annual review of the information available to us. This inspection looked at the following key questions: Safe, Effective and Well-led.

At the last inspection in August 2018 we rated the practice as good overall, and requires improvement for providing safe services because:

  • There were shortfalls in the systems for monitoring patients on some high-risk medicines.
  • The system to manage uncollected repeat prescriptions was not effective.
  • There were no records to confirm the action taken in response to safety alerts.
  • Some non-clinical staff were unclear about their responsibilities when acting as chaperones.
  • Reception staff had not been provided with training to assist them in identifying a deteriorating or acutely unwell patient.
  • Improvements were needed in the auditing of infection prevention and control.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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 good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Complete the outstanding actions identified in the latest infection prevention and control audit.
  • Improve the monitoring and security of blank prescriptions stored in consulting rooms.

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







Updated 14 September 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • Results from the GP patient survey (2017) were in line with local and national averages for questions relating to kindness, respect and compassion.
  • Patient feedback from the practice’s own survey was positive and in line with results from the GP patient survey.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them.
  • Results from the GP patient survey (2017) were in line with local and national averages for questions relating to involvement in decisions about care and treatment.
  • Patient feedback from the practice’s own survey was positive and in line with results from the GP patient survey.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.



Updated 14 September 2018

We rated the practice, and all of the population groups, as good for providing responsive service.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs. For example, a mobile application which could be downloaded to mobile devices had been created to signpost and support patients. The practice monitored user interaction with the application to identify areas for improvement.
  • Telephone and email consultations were available which supported patients who were unable to attend the practice.
  • The facilities and premises were appropriate for the services delivered. The practice had installed a ground floor toilet for patients with mobility difficulties who could not access the patient toilet on the first floor.
  • The practice made reasonable adjustments when patients found it hard to access services. For example, a new ramp had been installed at the main entrance to assist wheelchair users and patients with pushchairs.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.
  • An out-of-hours leaflet had been created to ensure patients knew how to access care services when the practice was closed.
  • The practice had upgraded their telephone system to improve efficiency for patients and staff.
  • The GP principal liaised with the local council regarding parking restrictions in the area and the difficulties for patients who required parking. As a result, short-term parking bays were created in the adjacent street to enable patients to park during their appointment.
  • The practice invited patients, their friends and family, and staff from other local practices to attend their annual basic life support training.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GPs accommodated home visits for those who had difficulties getting to the practice.
  • There was a medicines delivery service for housebound patients arranged by local pharmacies.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team and care coordinators to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, extended opening hours on Thursday evenings and email consultations. Practice news was also relayed via the practice website, mobile application and social media to update patients who could not regularly attend the practice.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • Patients could see a community mental health advisor who attended the practice every week.
  • The practice was flexible when booking appointments for patients with poor mental health. For example, appointments were booked during quieter times to reduce patients’ stress.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use. However, some feedback on the CQC comment cards showed working patients had difficulties getting an appointment. The practice prioritised early appointments and extended hour appointments for working patients.
  • The practices GP patient survey results were in line with local and national averages for questions relating to access to care and treatment.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.


Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable