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We are carrying out a review of quality at West Street Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 11 February 2020

The service is rated as Good overall.

We carried out an announced comprehensive inspection at West Street Surgery on 27 January 2020 to confirm that the practice had carried out the necessary improvements in relation to their breaches of regulation.

The practice received an overall rating of inadequate at our inspection on 20 September 2019 and 22 May 2019 and warning notices were issued.

The full comprehensive report from the September 2019 and May 2019 inspection can be found by selecting the ‘all reports’ link for West street Surgery on our website at .

Our judgement of the quality of care at this service is based 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.

The practice is rated a

s good overall.

(previously rated as inadequate in May 2019)

Key findings:

  • The practice was compliant with the warning notices issued in May 2019.
  • People who used the service were protected from avoidable harm and abuse, and requirements were met. Staff had a good understanding of how to escalate concerns.
  • There was effective audits and risk assessments in place in relation to fire, legionella, health and safety and infection prevention and control. Actions required were being completed.
  • There was effective management of medicines and prescribing including for medicines that required additional monitoring.
  • There was good oversight of pathology results and clinical practice. The practice had conducted clinical competency assessments and mentoring sessions that fed into individual appraisals.
  • Patients had good outcomes because they received effective care and treatment that met their needs.
  • Patients were supported, treated with dignity and respect and were involved as partners in their care.
  • Patients’ needs were met by the way in which services were organised and delivered.
  • Concerns raised regarding access to the practice via the telephone were being addressed by the introduction of an improved telephone system.
  • The practice delivered person-centred care and communicated effectively with community teams. They were flexible to the needs of the most vulnerable and complex patients.
  • The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
  • Regular staff meetings were held to ensure communication was clear and effective.
  • Staff were proud to work at the practice and were supported with their personal and professional development.

The area where the provider should make improvements are:

  • Continue to monitor and improve child immunisation uptake.
  • Continue to monitor and cancer screening and care planning uptake.
  • Continue to monitor and improve levels of patient satisfaction regarding lower than average indicators.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM 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