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Inspection Summary

Overall summary & rating


Updated 25 March 2019

We carried out this announced comprehensive inspection at Alexandra Surgery on 7 February 2019. We had previously carried out an announced comprehensive inspection on 18 January 2018. At that time the service was rated as requires improvement. It was rated as requires improvement for the safe, effective and well led domains and good for caring and responsive.

The areas where we said that the provider must make improvement were:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care with regards to: clinical governance, risk management, quality improvement, monitoring care and treatment for patients and patient engagement.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where we said the provider should make improvements were:

  • Ensure there is an effective system for monitoring prescriptions that have been issued but not collected.
  • Review the criminal records checks procedure for the practice.
  • Ensure business continuity and skill mix if the practice manager is absent for a significant period of time.
  • Improve uptake for screening programmes.

At this inspection we found that the practice had addressed all of the issued from the previous inspection, and 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.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Review the scheduling of clinical meetings so that further clinical staff may attend.
  • Review safeguarding and serious incidents even where concerns have not been raised.
  • Continue to review patient outcomes where scores are lower than the national or Clinical Commissioning Group area average, particularly in relation to uptake of cervical cancer screening.

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