• Doctor
  • GP practice

Mansion House Surgery

Overall: Good read more about inspection ratings

19-20 Irish Street, Whitehaven, Cumbria, CA28 7BU (01946) 693660

Provided and run by:
Mansion House Surgery

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Date of Assessment: 14/08/2025 to 27/08/2025. Mansion House Surgery is a GP practice in Whitehaven, Cumbria, and delivers service to 7,624 under a contract held with NHS England. The National General Practice Profiles states that 97.4% of patients are white and 22.2% are older people, both of which are higher than the national average. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the third decile (3 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

25 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced inspection ofMansion House Surgeryon 26 August 2015, during which a breach of a legal requirement set out in the Health and Social Care Act (HCSA) 2008 was found:

Regulation 18 HSCA of (Regulated Activities) Regulations 2014 : Staffing

The provider did not have in place suitable arrangements to ensure that staff employed within the practice were suitably supported in relation to their responsibilities as staff were not receiving regular opportunities for appraisal.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements set out in this regulation. They told us their action plan would be completed by 31 March 2016.

In April 2016 we undertook a focused inspection where we asked the practice to send us information to evidence that they now met legal requirements. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link forMansion House Surgery on our website at www.cqc.org.uk.

Our key findings were as follows:

  • The practice had taken action to address the issue identified during the previous inspection and put in place arrangements toensure staff appraisals foremployees were carried out on an annual basis.

However, the practice should continue with the programme of appraisals to ensure that all staff employed within the practice are suitably supported in relation to their responsibilities and offered the opportunity to identify personal development needs and training requirements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mansion House Surgery 25 August 2015. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Some risks to patients and staff were not assessed and systems and processes were not fully implemented to keep patients safe. For example, there were no assurance systems in place to confirm cleanliness and infection control procedures were effective. Small patches of damp were evident in the building.
  • Staff appraisals were not up to date for all staff groups
  • Although some clinical audits had been carried out, we saw no evidence that audits were planned effectively or driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available on request and easy to understand; however this was not as readily accessible to patients as it could have been.
  • Urgent appointments were usually available on the day they were requested; however patients said that they sometimes had to wait a long time for non-urgent appointments.
  • The practice had a number of policies and procedures to govern activity and held regular scheduled meetings for all staff groups
  • The practice had sought feedback from patients but did not have a patient participation group or website and was not included on the NHS Choices website.
  • The practice did not have a documented vision or business plan for the future; however they had identified some of the challenges faced. There was a leadership structure and staff felt supported by management. However, some of the systems and processes which should have been in place to keep patients and staff safe were not established.
  • The practice had been instrumental in the development of a Community Nursing scheme to ensure more co-ordinated care in the community for older patients. Although this was a clinical commissioning group (CCG) incentive the practice had been proactive in developing and piloting the scheme.
  • The practice had employed a care co-ordinator to support elderly, frail and palliative care patients
  • The practice hosted an on-site ultrasound and 24 hour ECG facility for the clinical commissioning group.

We saw one area of outstanding practice:

  • The practice had employed a care coordinator whose role was to ensure that appropriate care and support was in place for frail and elderly patients and those with dementia   

However, there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure that all staff are given the opportunity to have a regular appraisal.

In addition the provider should:

  • Review the process for identifying, carrying out and reviewing areas for clinical audit.
  • Continue with their plans to set up a patient participation group and practice website.
  • Develop a business plan to reflect and record aims, objectives, risk and mitigating actions.
  • Put in place appropriate arrangements to maintain a clean environment and assess the risk, detect, prevent and control the spread of infections by carrying out regular infection control audits.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice