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Alexandra Road Surgery Requires improvement Also known as Alexandra and Crestview Surgeries

Inspection Summary

Overall summary & rating

Requires improvement

Updated 17 September 2021

We carried out an announced inspection at Alexandra Road Surgery on 8 July 2021. Overall, the practice is rated as Requires Improvement.

The ratings for each key question are:

Safe - Requires Improvement

Effective - Requires Improvement

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection on 20 August 2019, the provider was rated Requires Improvement overall. We rated the provider as Inadequate for providing responsive services. and requires improvement for providing effective, caring and well-led services. We rated the provider as good for providing safe services.

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

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection:

  • We inspected the Safe, Effective Caring, Responsive and Well-led key questions.
  • We followed up on breaches of regulations identified at our previous inspection to ensure the required action had been taken.

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 data protection and information governance requirements.

This included:

  • Conducting staff interviews using staff questionnaires
  • 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, other stakeholders and people who use the service
  • A 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 overall and for the population groups families, children and young people, and working age people. The population group people with long term conditions is rated Inadequate. The population groups older people, people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia) are rated as Good.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm, however the provider is required to improve the way high risk medicines and other medicines requiring monitoring are managed.
  • Patients did not always receive effective care and treatment that met their needs, especially people with long term conditions.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care, however improvements were required in order to ensure high-quality, person-centred care was delivered.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

There were other areas the provider could improve and should:

  • Continue to review and improve consistency in recording do not attempt cardiopulmonary resuscitation (DNACPR) decisions.
  • Continue to improve staff communication and engagement.
  • Continue to monitor and take action on long standing medicines safety alerts.
  • Continue to monitor and reduce where appropriate, prescribing rates for Gabapentin and Pregabalin and multiple psychotropic medicines.

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


Families, children and young people

Requires improvement

Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable