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Inspection Summary

Overall summary & rating


Updated 25 March 2020

We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, this inspection looked at the following key questions: safe, effective, caring, responsive and well-led.

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 rated the practice as good overall. We rated the practice as requires improvement for the families, children and young people population group and good for all other population groups.

We rated the practice as good for providing safe, effective, caring, responsive and well-led services because:

  • 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 practice routinely reviewed the effectiveness and appropriateness of the care it provided. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Staff involved patients in their care and treatment decisions and treated them with kindness, dignity and respect.
  • The practice organised and delivered services to meet patients’ needs. 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 and an inclusive, supportive environment for staff. There was a focus on continuous learning and improvement at all levels of the practice.

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

  • Implement comprehensive staff related processes to include all staff completing essential training at the appropriate level for their roles, a review of the policy and process around staff Disclosure and Barring Service (DBS) checks including considering if all staff who chaperone should receive one, and nursing and paramedic staff receiving a formal, structured audit of their work (including prescribing and minor illness roles) against set criteria to assess their competency and autonomous decision-making.
  • Take steps so that existing infection prevention and control processes are strengthened. This includes those relating to defining, updating, or removing infection control audit actions and ensuring water temperatures at the practice are within the required levels.
  • Strengthen policies, systems and processes in relation to the appropriate management of Patient Group Directions (PGDs), the coding of completed patient medicine reviews on the clinical system, the timely and appropriate receipt of safety alerts including Medicines and Healthcare products Regulatory Agency (MHRA) alerts.
  • Increase the uptake of child immunisations and women attending for their cervical screening.
  • Continue to identify and support carers in the practice population.
  • Make the full complaints process and procedure readily available and accessible on the practice’s website.
  • Continue to take steps to improve levels of patient satisfaction in relation to the National GP Patient Survey results and access to the practice.

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)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable