You are here

Inspection Summary

Overall summary & rating


Updated 18 June 2019

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Safe
  • Effective
  • Well-Led

At the last inspection in June 2018, we rated the practice as requires improvement for providing safe services because:

  • The infection prevention and control policy was brief and missing key information such as waste and sharps management. There was an incident at the practice involving a needlestick injury which was handled incorrectly and potentially could have been avoided if clear policies and procedures were in place.
  • The practice employed an external cleaning company but there was no documentation to evidence the cleaning that took place within the practice. We found on the day of the inspection that the cleanliness of treatment rooms was not to an acceptable standard. We noted there was dirt and dust on the floor in two treatment rooms. This was also highlighted in the audit completed one week prior to our inspection but no action had been taken to remedy this.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We based our judgement of the quality of care at this service is 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 have rated this practice as Good overall.

The practice was rated as requires improvement for providing effective services because:

  • The practice’s uptake of cervical screening was below the 80% Public Health England target rate and below CCG and England averages.
  • The practice’s uptake of childhood immunisations was below the 90% World Health Organisation target rate and the practice told us this rate had reduced further in unpublished data.
  • The practice’s performance for outcomes for patients experiencing poor mental health was mixed and the practice told us this rate had reduced further in unpublished data. The practice’s exception reporting rate for mental health indicators was also higher than the CCG and England averages.
  • The practice had only completed 4 health checks out of 79 eligible patients diagnosed with a learning disability

We also rated the practice as good for providing safe, caring, responsive and well-led services.

The area where the provider must make improvements are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences

The areas where the provider should make improvements are:

  • Continue to review the prescribing of antibiotic items to ensure safe and appropriate prescribing.

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




Requires improvement






Checks on specific services

People with long term conditions


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)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement