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Inspection Summary

Overall summary & rating


Updated 6 August 2019

We decided to undertake an inspection of this service on 18 June 2019 following our annual review of the information available to us. This inspection looked at the following key questions; was the service providing effective and well led services for the registered patient population. We decided not to inspect whether the practice was providing safe, caring or responsive services as there was no information from the annual regulatory review which indicated this was necessary.

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.
  • Patients received effective care and treatment that met their needs.
  • Staff were developed and supported to ensure services were of high quality.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Governance systems were operated including quality improvement initiatives.
  • The practice was engaged in local initiatives and worked effectively alongside partners in the local healthcare system.

We found an area of outstanding practice:

The practice had reviewed and altered their website to provide information and services which enhanced patient experience and independence in accessing care and treatment. For example:

  • They had created a student website linked to the main website, dedicated to the needs of its University students. This enabled access to the relevant services online such as medical certificates or the ability to register with the practice online.
  • The practice had developed a video on the fitting of contraceptive coils. This included detailed information on the process and potential side effects including removal. This enabled patients to make an informed decision prior to attending appointments.

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

  • Consider whether the clinical team have the appropriate training to assess the rights and ability of patients under 16 to consent to care and treatment.
  • Review quality improvement processes to consider whether they should include exception reporting and cervical screening as areas for further development.

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