You are here

Inspection Summary

Overall summary & rating


Updated 27 May 2021

We carried out an announced inspection at All Saints Surgery on 29 April 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 12 July 2019, the practice was rated Requires Improvement overall, and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for All Saints Surgery on our website at

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • Breaches in Regulations relating to safe care and treatment and good governance.
  • Four best practice recommendations, which were:
  • Improve the identification of carers, including electronic coding systems to enable this group of patients to access the care and support they need.
  • Develop, seek and gather patient views.
  • Implement strategies to improve the uptake for cervical screening and the cancer screening programmes.
  • Implement strategies to improve the uptake of childhood immunisations for children under one year old.

How we carried out the inspection/review

Throughout the Covid 19 pandemic, CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

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 except Families, children and young people, and Working age people (including those recently retired and students) which we have rated as requires improvement in responsive.

This is because the practice has not met any of the five-childhood immunisation minimum targets; and that the uptake for cervical screening and the cancer screening programmes require further improvement.

We found that:

  • The practice had met the requirement notices we set in response to the breaches in regulation we found at the July 2019 inspection.
  • The practice had improved its processes to monitor patients on medicines to reduce the risk of blood clots and could demonstrate reviewing blood monitoring tests before these medicines were prescribed.
  • Patients on a specific medicine for blood pressure management received blood tests and these tests were reviewed prior to medicines being prescribed.
  • The practice had developed a system to prevent the duplication of prescriptions issued.
  • The practice had electronically coded patients notes for the out of hours service.
  • There was clear electronic coding for all family members when a safeguarding issue was identified.
  • 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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

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

  • Continue to Implement strategies to improve the uptake for cervical screening and the cancer screening programmes.
  • Further improve uptake of childhood immunisations for all children between 1 and 5 years old.

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










Checks on specific services

People with long term conditions


Families, children and young people

Requires improvement

Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable