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Inspection Summary

Overall summary & rating


Updated 23 December 2019

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 significant change to the quality of care provided since the last inspection.

We also carried out the inspection to follow-up on a breach of regulation identified at the previous inspection of the service in October 2018 in relation to patient satisfaction with access to appointments.

This inspection focused on the following key questions: effective, responsive and well-led.

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

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 with the exception of working age people (including those recently retired and students) population group which we rated as requires improvement.

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. However, cervical screening uptake was below the national target.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • The practice had improved access to appointments since the last inspection with data showing that patients could now access care and treatment in a timely way.
  • 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:

  • Improve cervical screening uptake to bring in line with national targets.
  • Continue to improve childhood immunisation uptake to bring in line with the World Health Organisation (WHO) target.
  • Implement a program of quality improvement including clinical audit to drive improvement in patient outcomes.
  • Implement a leadership development programme, including a succession plan.

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


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