You are here

The Aldergate Medical Practice Good

Inspection Summary

Overall summary & rating


Updated 30 July 2020

We carried out an announced comprehensive inspection at The Aldergate Medical Practice on 8 May 2019. 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, effective and well led. 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;

• Patients received effective care and treatment that met their needs.

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

• 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 person-centre care.

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

• The recruitment files we reviewed did not contain all the information required including staff vaccination history.

• The practice could not be assured that staff training was up to date as the staff training matrix was not up to date.

• The practice did not have documented risk assessments in place in relation to medicines for use in the event of an emergency not held at the practice.

• There were gaps in fire drills, patient safety alerts and serial number logs for paper prescription pads.

• There were gaps in the practice system for the repeat prescribing of a particular medicine.

• Significant events and incidents were reported documented and actioned with lessons learnt shared and disseminated. However, the system lacked a route cause analysis and therefore missed opportunities for further learning.

We rated the practice as good for providing effective services because:

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.

• The practice understood the needs of its population and tailored services in response to those needs. There was evidence of a number of projects and services the practice had been involved with to ensure patients’ needs were met.

We rated the practice as good for providing a well led service because:

• There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.

• 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 person-centre care.

• The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• Establish the recruitment system to ensure compliance with Schedule 3 requirements.

The areas where the provider should make improvements are:

• Develop the staff training matrix which enables clear oversight on all staff training.

• Further develop the significant event route cause analysis system.

• Improve the practice complaint leaflet and documentation.

• Improve staff awareness of the practice vision and values and their role in achieving them.

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








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