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Inspection Summary

Overall summary & rating


Updated 23 August 2019

We carried out an announced focused inspection at St Marys Surgery on 24 July 2019. We decided to undertake this inspection following our annual review of the information available to us. This inspection looked at the following key questions; safe, effective and well-led. Caring and Responsive were not reviewed because patient feedback and monitoring indicated no change since the last inspection. The rating from the last inspection has been carried forward.

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.

•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 had clear systems, practices and processes to keep people safe and safeguarded from abuse. Staff spoken with understood their responsibilities.
  • The practice learned and made improvements when things went wrong. Leaders promoted a culture of reporting and recording all incidents, including near misses, as significant events. These were reviewed monthly and an annual review undertaken to identify themes and trends.
  • The practice understood the needs of its population and tailored services in response to those needs.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment and worked together and with other organisations to deliver effective care and treatment.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. All clinicians were up to date with guidance.
  • Staff felt supported by the management team, proud to work at the practice and able to raise concerns.
  • The practice responded to patient feedback and had made changes that had been suggested by their patient participation group
  • There was compassionate, inclusive and effective leadership. Leaders were visible and approachable and understood the strengths and challenges of the services provided.

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

  • Review the system and process to ensure all medical alerts are received, acted upon and monitored in a timely manner.

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)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable