During an assessment under our new approach
Well Street Surgery was assessed due to an assessment not having taken place since January 2016. This assessment took place between 18 February 2026 and 5 March 2026.
The National General Practice Profiles states that the practice population includes 7.5% mixed, 9.4% Asian, 24.6% Black, and 6.2% other non-white ethnic groups.
Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 3rd decile (3 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.
SAFE: The service had a positive learning culture, and staff could raise concerns openly. When incidents occurred, they were investigated and lessons shared. Facilities and equipment met people's needs and were clean and well-maintained, and there were enough staff with the right skills, qualifications and experience. We identified areas where the provider's documented systems for overseeing safety were not always effective, including gaps in risk registers, recruitment documentation, infection prevention and control audit, and the monitoring of some high-risk medicines. These findings reflected weaknesses in governance and documented oversight rather than unsafe clinical practice, and no evidence of patient harm was identified. The provider responded promptly to each concern raised, and the underlying governance issues are addressed under the Well-led key question and the associated Regulation 17 breach.
EFFECTIVE: People were involved in assessing their needs. Staff regularly reviewed these assessments and considered each person’s communication, personal, and health needs.
Care was based on up-to-date evidence and good practice. Staff worked with other services involved in people’s care to achieve the best outcomes and ensure smooth transitions when people moved between services. Staff also made sure people understood their care and treatment so they could give informed consent.
CARING: People were treated with kindness and compassion. Staff respected their privacy and dignity, treated them as individuals, and supported their personal preferences. People were given choices about their care and treatment. The service also supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. The service provided information in a way that people could understand. People knew how to give feedback and felt confident that the service listened and acted on their concerns. The service was easy to access and worked to reduce discrimination. People received fair and equal care and treatment.
WELL-LED: We found that the provider did not have strong governance systems in place to ensure consistent oversight of safety, quality and performance. Although the practice had a positive culture and staff were committed to providing safe care, there was no clear, documented governance framework. This meant that a number of issues relating to clinical oversight, premises risk, recruitment, training and infection prevention and control had not been identified by the provider prior to inspection, as set out under the Safe and Well-led key questions of this report. We identified a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to submit an action plan within 28 days to address the concerns identified during this assessment. The provider was approachable, open and responsive throughout, and submitted an action plan and supporting evidence by the end of the assessment period.