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Inspection Summary

Overall summary & rating


Updated 2 August 2019

We carried out a focused inspection at Charles Road Surgery on 27 June 2019 as part of our inspection programme.

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:

  • Are services at this location effective?
  • Are services at this location responsive?
  • Are services at this location well-led?

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:

  • Patients received effective care and treatment that met their needs.
  • Patient outcome data (QOF) and prescribing performance was in line with CCG and national averages.
  • Staff had appropriate skills and experience to meet patient needs.
  • The practice organised and delivered services to meet patients’ needs.
  • Patients could access care and treatment in a timely way.
  • Complaints were managed appropriately and in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Risks were generally well managed. Although we identified areas where these could be improved for example in relation to infection control and completion of audit cycles.

We have rated this practice as requires improvement for the working age population group.

We found that:

  • The practice uptake of cervical cancer screening and bowel cancer screening was below local and national averages. The practice staff were aware of the cultural sensitivities and expectations in relation to health care however, no clear plans of action had been implemented as to how this might be improved.

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

  • Review cervical screening and child immunisation data and identify how this may be improved.
  • Review service improvement activity to ensure improvements are sustained through completed audit cycles.
  • Revisit infection control audit to identify areas for improvement and take action as appropriate.
  • Consider on an individual basis the provision of a formal written care plan to be provided to relevant patients.

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










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)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable