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The Aldergate Medical Practice Good

Inspection Summary

Overall summary & rating


Updated 27 August 2021

We carried out an announced desk based review at The Aldergate Medical Practice on 29 April 2021 to follow up on the findings from the last inspection on 8 May 2019. During the inspection on 8 May 2019, the practice was rated Good overall and for key questions effective, caring, responsive and well-led. It was rated requires improvement for key question safe.

The desk based review on 29 April 2021 highlighted potential issues with monitoring the health of patients prescribed high risk medicines and management of safety alerts, which required further investigation. Consequently, we carried out an announced inspection on 15 July 2021. Following our review of the information available to us, including information provided by the practice, we focused on the following key questions: safe, effective and well-led.

Overall, the practice is rated as Good. Following our review on 15 July 2021, it is rated as good in safe, effective, caring, responsive and well-led, as well as in all of the population groups.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Aldergate Medical Practice on our website at

Why we carried out this review

This review was a review of information without undertaking a site visit inspection to follow up on:

  • Breaches in Regulation 17 HSCA (RA) Regulations 2014 Good governance and Regulation 19 Fit and Proper Persons Employed.
  • Four best practice recommendations
  • 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.

How we carried out the review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • Speaking with care home staff
  • Speaking with the chairperson of the Patient Participation Group
  • A site visit

Our findings

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 had actioned and put measures in place for all the improvements areas identified in the previous inspection, including the breaches in regulation.
  • Staff spoke highly about the management team and commented that leaders were visible and approachable. Staff felt supported and valued in their work.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Recruitment procedures had been improved and the required recruitment checks had been carried out for newly recruited members of staff.
  • Improvements had been made to the management of paper prescription pads, risk

assessment completed for the suggested emergency medicines not held in the practice, fire drills held and root cause analyses completed for significant events.

  • The desk based review highlighted potential issues linked to the monitoring the health of patients prescribed high risk medicines and the management of safety alerts. The practice completed a number of audits following the review and had taken appropriate action and improvements had been made.
  • Patients received effective care and treatment that met their needs.
  • Staff had the skills, knowledge and experience to carry out their roles. There was a system in place to monitor compliance with staff training. Staff were encouraged and supported to develop their skills and move to new roles with the practice.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. 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. Consideration was given to succession planning and the practice had been innovative with new staff recruitment, providing patients with a variety of healthcare professionals to provide a service, as well as developing the skills and knowledge of existing staff.

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

  • Update the safeguarding policies to reflect the current requirements for staff training.
  • Record positive significant events, which provide the opportunity to share good practice.
  • Dispose of sharps boxes three months from the date of opening.
  • Continue to encourage and improve the uptake of cervical screening.
  • Continue to monitor and improve outcomes for patients with long term conditions.
  • Update the registration of the Registered Manager with the Care Quality Commission.

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