During an assessment under our new approach
Date of Assessment: 22 September and 24 September 2025. Church Lane Surgery is a GP practice, located in Brighouse, West Yorkshire, which delivers services to approximately 11,000 patients under a contract held with NHS England. The National General Practice Profile states that the practice demographic is 93% White, 3% Asian, 2% Mixed, 1% Black and 1% Other. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the sixth decile (6 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 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.
We assessed this practice due to the length of time since our last inspection. This was an announced assessment looking at all the quality statements and all key questions. At this assessment we found:
Safe: The practice had a good learning culture, staff could raise concerns, and managers investigated incidents thoroughly. However, we found some gaps in systems and processes around medicines management and the management of some patients with long-term conditions, safeguarding, safe environments, safe and effective staffing and infection prevention and control.
Effective: Patients were involved in assessments of their needs. Staff made sure patients understood their care and treatment to enable them to give informed consent. Staff reviewed assessments taking account of their communication, personal and health needs. Staff involved those important to patients and took decisions in their best interests where they did not have capacity. However, we highlighted gaps in the management of some patients with long-term-conditions in line with national guidance.
Caring: Patients were treated with kindness and compassion. Staff demonstrated how they protected patient privacy and dignity and treated patients as individuals and supported their preferences. This included cultural, communication and accessibility requirements. Outcomes from the most recent National GP Patient Survey were positive and demonstrated patients felt listened to, supported, and involved in decisions about their care. The practice supported staff wellbeing.
Responsive: Patients were involved in decisions about their care. The practice provided information in a manner people could easily understand. Patients were able to access suitable appointments, based on clinical need, and vulnerable people or those with protected characteristics were able to access care and treatment in ways that met their personal circumstances. The National GP Patient Survey outcomes were broadly in line with national averages in relation to access. The practice took complaints and other patient feedback seriously and learnt from them to improve the quality of care.
Well-Led: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Leaders demonstrated a commitment to continuous improvement, using feedback from people using the service, families, and staff to inform service development. The practice was a training practice and demonstrated a strong education and learning ethos. The practice engaged positively in the assessment process, were responsive, proactive and acted immediately on feedback.
We have rated this service good overall and good for all the key questions except the key question safe, which has been rated as requires improvement, due to a breach of regulation in relation to Regulation 12 – Safe care and treatment. We have asked the provider for an action plan in response to the concerns found at this assessment.