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Staverton Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 March 2020

We carried out an announced comprehensive inspection at Staverton Surgery on 9 January 2020 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: safe and well-led.

We based our judgement of the quality of care at this service is 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 requires improvement overall.

We rated the practice as requires improvement for providing safe and effective services because:

  • Staff vaccination was not maintained in line with Public Health England (PHE) guidelines.
  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • Appropriate standards of cleanliness and hygiene were not always met.
  • Clinical data was not always managed securely according to guidance.
  • The systems for the appropriate and safe use of medicines was not always operating effectively.
  • The practice did not have an effective system to learn and make improvements when things went wrong.
  • The processes to keep clinicians up to date with current evidence-based practice were not effective.
  • There was limited monitoring of outcomes of care and treatment.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way for patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. In particular, keeping clinicians up to date with current evidence based practice.

In addition, the provider


  • Develop a system to monitor pharmacist registration to ensure it is kept up to date.
  • Develop a system to monitor clinician performance and carry out peer reviews.
  • Take action to improve uptake for cervical screening.
  • Develop a clear audit strategy.

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


Requires improvement


Requires improvement






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