During an assessment under our new approach
Fell Cottage Surgery is a GP practice and delivers service to 8,811 Patients under a contract held with NHS England.
The National General Practice Profiles states that according to the latest available data, the ethnic makeup of the practice area is 93.76% White, 2.41% Asian, 1.03% Black, 1.24% Mixed and Other 1.56%. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6 decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The last comprehensive inspection of this service took place in March 2016, when it was rated as good overall and for the key questions of safe, effective, caring, responsive and well led.
We carried out this assessment on 8 and 14 April 2026 as a fully comprehensive inspection. The reason for the assessment was the length of time since the last inspection.
For this assessment the service maintained its overall rating of good.
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience, but there was no oversight of non-clinical staff immunisations in line with guidance. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well however a few issues were identified where patients were overdue for their medicines review. Emergency medicines and equipment were in place however there was no documented local risk assessment to determine which medicines should be held. These issues were quickly resolved following the assessment.
Staff took account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to make decisions in people’s best interests where they did not have capacity. People were involved in assessments of their needs, however, we found some had not been completed in line with guidance.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement, with staff given time and resources to try new ideas. Managers made sure staff received regular appraisals to maintain high-quality care. Staff mandatory training was up to date. However, we identified some inconsistencies in the type and frequency of training recorded for a small number of staff in the new electronic management system. This was addressed promptly.