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Inspection Summary

Overall summary & rating


Updated 26 April 2019

We carried out an announced comprehensive inspection at Austen Road Surgery on 4 March 2019 as part of our inspection programme.

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 and
  • 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 provided care in a way that kept patients safe and protected them from avoidable harm.
  • Risks were adequately managed and mitigating actions were in place. The practice had addressed previous concerns around health and safety, fire safety and the risk of legionella.
  • Patients received effective care and treatment that met their needs.
  • There was higher than average exception reporting in relation to mental health indicators.
  • The practice monitored performance around patient outcomes and were in line with national and local averages in most areas. However, there was evidence on the day of inspection that not all patients were recalled for monitoring in a timely way.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had improved access to training for staff and we saw evidence of a developing culture of learning.
  • 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.
  • There was evidence of some quality improvements processes in place, however oversight and sharing of clinical audits and quality improvement activities was not comprehensive.
  • Staff were positive about working in the practice and were supported in their roles.
  • The practice had begun working on centralising staff vaccination records and were collecting information to ensure that all relevant staff were appropriately vaccinated.
  • Minutes of meetings were not comprehensively recorded.

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

  • Review and improve how patients are recalled for annual reviews and monitoring of treatment.
  • Coordinate clinical audits and quality improvement activities so that there is oversight and shared learning.
  • Review exception reporting in relation to mental health indicators.
  • Improve how meeting minutes are recorded.
  • Continue to review the recording of staff vaccination in line with Public Health England guidance.

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