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Inspection Summary

Overall summary & rating


Updated 20 November 2019

We carried out an announced comprehensive inspection of Avisford Medical Group on 27 February 2019. The overall rating for the practice was good. The practice was also rated good for providing safe, effective, caring and responsive services. All the population groups were rated good. It was, however, rated as requires improvement for providing well-led services. This was because: -

  • Learning from significant events and complaints was not always used or shared effectively to make improvements.

The full comprehensive report on the 27 February 2019 inspection can be found by selecting the ‘all reports’ link for Avisford Medical Group on our website at .

After the inspection in February 2019 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was an announced focused inspection carried out on 20 September 2019 to ensure that the practice was now complying with the regulations.

Overall the practice continues to be rated as good, however it is still rated as requires improvement for providing well led services.

At this inspection our key findings were: -

  • There was some evidence to show that the practice regularly discussed significant events and complaints and shared the findings and some of the lessons learned with staff.

However, we also found: -

  • Whilst the practice had a policy for reporting significant events, it did not make clear what constituted a significant event or how they should be prioritised.
  • The practice did not maintain an accurate or complete chronological log or summary of significant events to enable it to monitor action and identify trends.
  • Records of significant events were brief and there was limited evidence to show whether enough information gathering or investigations in to the root cause had taken place.
  • Appropriate action and lessons learned were not always identified.
  • There was limited evidence to show that agreed actions had been monitored or implemented.
  • The practice did not maintain a clear audit trail or accurate log of complaints
  • Complaints records indicated that learning was not always widely shared and that a culture of openness and transparency was not embedded.
  • The practice had not implemented a system for assuring that all safety alerts received were disseminated appropriately and acted on.

The areas where the provider must make improvements are:

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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