During an assessment under our new approach
Date of Assessment:13 May 2026. Capelfield Surgery is a GP practice and delivers services to approximately 7,770 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 89.5% White, 5.13% Asian, 3.44% Mixed, 0.3% Black and 1.5% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 10th decile of 10. The lower the decile, the more deprived the service population is relative to others.
This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. 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.
Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe, although, on the day of inspection, we noted the Legionella risk had increased to high. We were assured the provider had taken appropriate action and was effectively managing the risk to keep people safe. The service assessed and managed the risk of infection well and took steps to control the risk of it spreading.
There were enough staff with the right skills, qualifications and experience.
Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.
Staff were very good at treating people with kindness, empathy and compassion and supporting their needs as well as respecting their privacy and dignity.
People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.
The service did not always have clear and effective governance processes related to the assessment and management of risk within the service. However, leaders accounted for the actions, behaviours and performance of staff and the service had a clear vision which considered the needs of the people who used their service and the wider community. Roles and responsibilities were clear and understood by staff.
We found 1 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.