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Oldfield Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 September 2021

We carried out an announced inspection at Oldfield Surgery from 27 July to 11 August.

Overall, the practice is rated as Requires Improvement.

The ratings for each key question are as follows:

Safe - Requires Improvement

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led – Requires Improvement.

Following our previous inspection on 19 May 2019, the practice was rated Requires Improvement overall and for the safe and well-led domains. The practice was rated as good in all other areas.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on the breach of regulation 17: Good Governance, found in May 2019.

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
  • 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

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 Requires Improvement and for the provision of safe, effective and well-led services. We have rated the population groups as rated Requires Improvement for long-term conditions and people experiencing poor mental health and good for all other population groups.

We found that:

  • Some of the systems and processes continued to require further improvements to provide the leadership team with assurances and oversight of the practices quality of care. In areas such as medicines management, , recruitment, staff vaccinations and the management of long-term conditions and people experiencing poor mental health.
  • The provider, Heart of Bath, had an active clinical research unit, run day to day by a clinical research nurse and study coordinator. Supported by a core research team that included two GP Partners, who were currently involved in over 20 research studies, working closely with the National Institute of Health Research (NIHR), universities and commercial sponsors. Since March 2020 they had focused on supporting Urgent Public Health Research, such as the Principal Trial, Virus Watch and surveys to understand the psychological response to the Covid-19 pandemic.
  • Patient experience surveys, taken following the research were positive, commenting that their experiences consistently exceeded expectations.
  • The provider, Heart of Bath, was a standalone Primary Care Network, that had fully supported the COVID 19 vaccination program for over 28,000 patients.
  • The surgery had systems and processes to keep people safe and safeguarded from abuse.
  • Staff had the information they needed to deliver safe care and treatment.
  • The practice learned and made improvements when things went wrong.
  • Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
  • The practice organised and delivered services to meet patients’ needs.
  • Staff reported the culture had improved as staff had risen to the challenges of working during the pandemic.
  • Staff described the leadership as improved and supportive.

We found breaches of regulation. The provider must:

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

The provider should:

  • Record the supervision of clinical staff.
  • Put a system in place that provides a safety net for the management of abnormal cervical smears.
  • Work towards achieving the national target for cervical screening of 80%.
  • Continue to monitor and improve patient access.

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


Requires improvement


Requires improvement






Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

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)

Requires improvement

People whose circumstances may make them vulnerable