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Inspection Summary

Overall summary & rating


Updated 13 October 2021

We carried out an announced inspection at The Fryent Way Surgery on 09 September 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Requires Improvement

Effective - Good

Well-led - Good

Following our previous inspection on 01 August 2019 the practice was rated Requires improvement overall and for the key questions safe and well-led. The key questions effective, caring and responsive were rated good.

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

This inspection was a focused inspection on the key questions safe, effective and well-led. It was also carried out to follow-up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance.

Why we carried out the inspection

We carried out this focused inspection to follow up on the breaches of Regulation identified at the previous inspection.

How we carried out the inspection

Throughout the 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.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, some areas of clinical risk management needed improving.
  • Patients received effective care and treatment that met their needs.
  • 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.

We found one breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way.

In addition, the provider should:

  • Continue to improve cervical screening and childhood immunisation performance to bring in line with national targets.
  • Continue to develop the patient participation group to gain feedback from patients and improve the service provided.

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


Requires improvement








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