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Hilltops Medical Centre Good

Inspection Summary

Overall summary & rating


Updated 1 September 2021

We carried out an announced inspection at Hilltops Medical Centre between 29 July and 3 August 2021. Overall, the practice is rated as good.

The ratings for each key question are:

Safe - Good

Effective – Good

Well-led – Good

Following a previous focused inspection on 15 October 2019, the practice was rated requires improvement overall and with a rating of requires improvement for providing safe and well led services and a rating of good for providing effective services and for all population groups.

We then carried out a remote review of Hilltops Medical Centre on 9 December 2020. This was undertaken to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in Regulation 12 safe care and treatment as set out in a requirement notice following our inspection in October 2019.

As a result of continued breaches of regulation being identified at our remote review a warning notice was issued to the provider in December 2020.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on:

  • The safe, effective and well-led key questions
  • The breaches of regulation and ‘shoulds’ identified in the previous inspection. These are areas where we identified the provider should make improvements.

The practice had previously been rated good for the Caring and Responsive key questions following our comprehensive inspection on 26 November 2018.

The information we received and reviewed as part of this inspection did not indicate the previous rating of good for providing caring and responsive services was affected and therefore these ratings were carried over.

How we carried out the inspection

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 inspections 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 and telephone calls.
  • 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.
  • A short site visit.
  • Asking patients to submit online feedback.

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 for all population groups.

We found that:

  • The breaches in regulation issued in our warning notice in December 2020 had been met.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had processes for managing risks, including safety alerts.
  • The practice identified and learnt from significant events.
  • Patients received effective care and treatment that met their needs.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • They had made improvements to governance arrangements and managing risks. Practice policies and procedures were followed.

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

  • Continue to embed the implementation of the new online practice portal, particularly in relation to the management of significant events.
  • Seek innovative ways to improve patient outcomes in the Quality and Outcomes Framework.
  • Take actions to improve the levels of patient satisfaction particularly in relation to telephone access and appointment booking.
  • Seek innovative ways to encourage eligible patients to have cervical cancer screening.
  • Ensure information about the Parliamentary and Health Service Ombudsman is included in all complaint final response letters.

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






Insufficient evidence to rate


Insufficient evidence to rate


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