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Inspection Summary

Overall summary & rating


Updated 17 December 2019

This inspection was a carried out in response to our findings during our on-going monitoring of the practice. The inspection was an announced focussed inspection, which we undertook on 29 October 2019, under Section 60 of the Health and Social Care Act 2008. This report covers our findings in relation to the effective, responsive and well-led key questions. The ratings for the safe and caring key questions will be carried through from the previous inspection on 13 September 2017, when the practice was rated as good overall and in the safe, effective, caring and well-led key question. The responsive key question was rated as requires improvement.

At this inspection, the practice was rated requires improvement in effective and good in the responsive and well led key questions. Three of the six population groups were rated good. Families, children and young people, people with long-term conditions and working age people were all rated requires improvement.

The reports of all the previous inspections of Conway PMS can be found by selecting the ‘all reports’ link for Conway PMS on our website at

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 and the public.

We rated the practice as requires improvement for providing effective services because:

  • The practice is below the CCG and national target in several 2018/19 QOF performance indicators; namely, families, children and young people, People with long-term conditions and working age people. The practice had identified these areas and had a plan to improve their performance but was not yet able to demonstrate improved outcomes.
  • The practice was unable to demonstrate that it always monitored and obtained consent appropriately.

We rated the practice as good for providing responsive services because:

  • Feedback from patients was acted upon and as a result, extended opening hours from 7am have been introduced on a long-term basis, as well as a new telephone system and online booking feature.
  • The practice actively sought input from external organisations and charities to improve services offered.
  • The practice actively offered patient choice with regards to care and treatment options. All nine of the patients interviewed stated they felt involved in the decisions made at the practice.

We rated the practice as good for providing well-led services because:

  • The practice had been responsive to feedback from our previous inspection and had addressed all our findings.
  • Governance of the practice promoted the delivery of high-quality and person-centred care, supported learning and innovation, and promoted an open and fair culture.
  • Staff understood the practice’s vision, values and strategy, and their role in achieving them.
  • Arrangements with partners and third-party providers were governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care.

There were areas were the practice should make improvements:

  • Improve the process in place for the recording and monitoring of patient consent.
  • Continue to take steps to improve cervical cancer screening and childhood immunisation uptake.
  • Improve patient satisfaction with booking appointments further into the future.
  • Improve the process in place for reception staff knowing which type of appointments to book.

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

Requires improvement

Families, children and young people

Requires improvement

Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable