• Doctor
  • GP practice

Elm Surgery

Overall: Good read more about inspection ratings

123 Leypark Walk, Estover, Plymouth, Devon, PL6 8UF (01752) 776772

Provided and run by:
Elm Surgery

Latest inspection summary

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Background to this inspection

Updated 10 November 2022

Elm Surgery is located in Plymouth at:

123 Leypark Walk




The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Devon Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS). This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices - Sound Primary Care Network (PCN).

Information published by Public Health England shows that deprivation within the practice population group is in the fifth decile (five of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 97% White, 1.9% Asian, 0.6% Other, and 0.5% Mixed.

The age distribution of the practice population closely mirrors the local and national averages.

There is a team of 10 GPs who provide cover at the practice. There were five partners, one salaried GP, three registrars (doctors who were in training to become General Practitioners) and one locum GP. The practice has a team of two nurses who provide nurse led clinics for long-term conditions, one health care assistant and one GP assistant.There was a team of acute healthcare professionals, including a paramedic, an acute nurse practitioner and a physiotherapist. The GPs are supported at the practice by a team of seven reception staff and three administration staff. The practice manager and operations manager were also in place to provide managerial oversight.

The practice is open between 8 am to 6 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Overall inspection


Updated 10 November 2022

We carried out an announced focused inspection at Elm Surgery on 28 September 2022. Overall, the practice is rated as good.

Safe – good,

Effective - good,

Caring - not inspected, rating of good carried forward from previous inspection,

Responsive - not inspected, rating of good carried forward from previous inspection,

Well-led – good.

Following our previous inspection in March 2016, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Elm Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The practice was chosen as a sample of good and outstanding services to confirm our direct monitoring approach.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • 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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Not all infection and prevention control processes were fully embedded into practice such as risk assessments and outcomes of actions.
  • Patients received effective care and treatment that met their needs.
  • Staff interacted with patients with kindness and respect.
  • 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-centre care.
  • The practice was resilient to challenges and continued to provide care and treatment to patients in a safe, effective and well-led way.
  • The practice were quick to respond to feedback implementing newly actioned processes following our inspection.

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

  • Make sure there are appropriate Infection Prevention Control measures in place, including a regular audit and that all the action are completed as per timescales recognised in the audit.
  • Make sure all patients with long-term conditions and on high-risk medicines in need of regular reviews had those in place.
  • Improve cervical cancer screening uptake to make sure it meets the national targets.

We found the following areas of outstanding care:

The practice demonstrated resilience, as they have continued to provide safe, effective and well-led services throughout the COVID-19 pandemic and through the challenge of a growing practice population. This had increased from 6,000 to over 9,500 patients since the last inspection in 2016.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services