During an assessment under our new approach
Date of Assessment: 17 to 24 March 2026.
Catterick Village Surgery is a GP practice which delivers services to 6,061 patients under a contract held with NHS England. The service has a branch site of this main location at Colburn Surgery (Easton Way, Colburn, Catterick Garrison, DL9 4GA).
The National General Practice Profiles state the population of Catterick Village Surgery consists of 93.36% white, 3.18% Asian, and 1.26% Black patients, with less than 1% of patients mixed race, and 1.23% of another ethnicity.
Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th decile (8 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 practice, the context the practice was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We rated the key question of safe as requires improvement.
The provider did not complete appropriate risk assessments of their facilities to ensure they were clean, safe and well-maintained. They did not store waste safely. Staff did not always take appropriate action to safeguard vulnerable patients. Staff recruitment documentation was not comprehensive and was difficult to access. However, 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. The practice had a good learning culture. Staff could raise concerns. Managers investigated incidents thoroughly. Staff made sure medicines and treatments were safe for patients and met their needs. The practice worked well with partner organisations to ensure safe care for patients. Staff were alert to signs of patient discomfort and knew how to respond if a patient’s health suddenly deteriorated.
We rated the key question of effective as good.
Patients were involved in the assessments of their needs. Staff took account of people’s communication, personal and health needs when reviewing their assessments. 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 patients understood their care and treatment to enable them to give informed consent. When a patient did not have capacity, staff involved people important to the patient (such as family, friends and carers) to ensure decisions made were in their best interests.
We rated the key question of caring as good.
The practice was good at treating people with kindness and compassion. Staff treated patients as individuals and supported their preferences. They worked hard to help patients retain their independence. Staff responded quickly and appropriately when patients needed help. People had choice in their care and treatment. Staff protected the privacy and dignity of patients. The practice supported staff wellbeing.
We rated the key question of responsive as good.
The practice was good at ensuring patients (and the people supporting them) were involved in decisions about their care. They made sure patients could access the care, support and treatment they needed when they needed it. People were supported to consider their wishes about care at the end of their life. The practice understood the diverse health and care needs affecting their patients and the local community. They worked in partnership with other services to meet the needs of their patient population. The practice worked to eliminate discrimination. Patients received fair and equal care and treatment. The practice proactively worked to reduce health and care inequalities. However, the practice did not always provide clear and up-to-date information. Patients did not know what to expect if they wanted to complain.
We rated the key question of well-led as requires improvement.
The provider did not ensure effective governance processes were in place to ensure appropriate oversight of all areas of their service. They did not complete regular audits to evaluate and improve their practice. They did not maintain appropriate personnel records for staff. However, leaders were visible, knowledgeable and supportive. Leaders and staff had a shared vision and culture based on openness, respect, compassion, and accountability. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Leaders worked with the local community to deliver the best possible care and were receptive to new ideas. Staff told us there was a positive culture at the practice which ensured dignity and respect for patients.
We found a breach of regulation in relation to good governance.
We have asked the provider for an action plan in response to the concerns found at this assessment.