You are here

Staverton Surgery Requires improvement


Inspection carried out on 9 January 2020

During an inspection looking at part of the service

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 carried out on 15 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Staverton Surgery on 15 March 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice