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Inspection Summary

Overall summary & rating


Updated 24 July 2019

We carried out an announced comprehensive inspection at The Saltscar Surgery in January 2019. The overall rating for the practice was requires improvement. We made this judgement in January 2019 because arrangements in respect of; incident reporting processes, infection prevention and control, systems of assurance and overarching governance needed to be improved. The full comprehensive report on the January 2019 inspection can be found by selecting the ‘all reports’ link for The Saltscar Surgery on our website at

This inspection was undertaken following as an announced comprehensive follow-up inspection on 3 July 2019. Overall the practice is now rated as good.

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.

Our key findings were as follows:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff were aware of current evidence-based guidance. Staff had been trained and had the skills and knowledge to deliver effective care and treatment.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

We saw one area of outstanding practice:

The practice had a proactive approach to safeguarding


We saw evidence of effective inter-agency working with regard to safeguarding. Some non-clinical staff had been trained to safeguarding level three and undertaken some additional training about specific vulnerabilities within safeguarding, for example; coercive behaviours and vulnerable, exploited, missing and trafficked (VEMT). Using their additional training, these members of staff, under the support and supervision of the lead GP, prepared reports for safeguarding strategy meetings and case conferences. We saw evidence of multi-agency case discussions, SAFER referrals (a referral for concern developed by the Tees wide local safeguarding board) and follow-up of outcomes. The practice had implemented the ‘Think Child’ concept into its care and treatment of families. The practice had applied the theoretical learning from safeguarding training, to real situations with patients, and could demonstrate successful outcomes where significant risks had been reduced for those patients, as a direct result of action by the practice (including appropriate professional challenge). Lessons learned from serious case reviews had been considered and applied, when the practice was acting on information of concern.

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

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

  • Continue to complete some outstanding medication reviews and improve the system for coding patients who have had a medication review.
  • Carry out regular searches of patients of child-bearing age who are prescribed certain long-term medicines.

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)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable