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Inspection Summary

Overall summary & rating


Updated 7 April 2020

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Effective
  • Well Led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Safe
  • Caring
  • Responsive

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 received 54 CQC feedback cards about patient care and experience, these cards were given to patients before and during the inspection. Comments made by patients were positive about the services provided and the practice staff. A small number of negative comments related to patient access for GP appointments and car parking.

We have rated this practice as good overall and good for all population groups.

We found that:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The practice had a comprehensive programme of quality improvement and used information about care and treatment to make improvements.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
  • Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved.
  • The practice actively identified people who may need extra support to live a healthier lifestyle. Staff provided advice and information i.e. leaflets, so people can self-care.
  • The practice monitored the performance targets for long term conditions which at the time of inspection required improvements.
  • The practice understood the needs of its local population and had developed services in response to those needs.
  • There was evidence that complaints were used to drive continuous improvement. However, the organisation of this information required improvements.
  • Practice leaders had the experience, capacity and skills to deliver the practice strategy and address risks to it. The practice had undergone a number of challenges across the previous year related to opening a branch surgery while taking over a neighbouring practice. We found that the leadership team were knowledgeable about the issues and priorities relating to the quality and future of the service.
  • The practice had a culture which drove high quality sustainable care. There were governance structures and systems which were regularly reviewed and there were clear and effective processes for managing risks, issues and performance.
  • The practice engaged with staff and patients to develop services.

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

  • Develop central management systems for the effective oversight and management of practice complaints, staffing recruitment and training.
  • Review the systems in place for the storage of medical records to ensure they are accessible, their integrity is protected against loss or damage, and patient confidentiality is maintained.
  • Review all complaints made to the practice annually to identify trends and themes.
  • Continue to review and monitor the data that falls below the Clinical Commissioning Group (CCG) and national averages.

Inspection areas










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