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Inspection Summary

Overall summary & rating


Updated 8 April 2019

We carried out an announced comprehensive inspection at Cantilupe Surgery on 12 February 2019 as part of our inspection programme. The practice was previously inspected on 15 October 2014 and rated good overall.

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 have rated this practice as good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse and for identifying and mitigating risks of health and safety.
  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines and best practice.
  • Patients’ needs were assessed and care delivered in line with current guidelines. Staff had the appropriate skills, knowledge and experience to deliver effective care and treatment.
  • Staff treated patients with kindness and respect and involved them in decisions about their care.
  • Patient feedback from the national GP patient survey was positive with all results above local and national averages.
  • Urgent same day patient appointments were available when needed. All patients who completed comment cards told us they were always able to obtain same day appointments and access care when needed.
  • There was an open and transparent approach to safety and a system in place for recording, reporting and learning from significant events. The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • There were clear responsibilities, roles and systems of accountability to support effective governance.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

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

  • Take action to ensure that the risk assessment for the premises was kept under review so that staff could feel confident that details were up to date at all times.
  • Review the system to ensure that all staff receive safeguarding training suitable for their role.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable