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Inspection Summary

Overall summary & rating


Updated 30 December 2019

We decided to undertake an inspection of this service on 21 November 2019 following our annual review of the information available to us which took place in April 2019. This inspection looked at the following key questions; was the service providing effective and well led services for the registered patient population. We decided not to inspect whether the practice was providing safe, caring or responsive services as there was no information from the annual regulatory review which indicated this was necessary.

The practice remains rated Good overall.

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 good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff were developed and supported to ensure services were of high quality.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice had planned services to meet the demands of a rapidly increased practice population and had managed the increase of 3,000 patients effectively.
  • The practice was aware of patient feedback in regards to access to services and took action to maintain appropriate access.
  • Services were tailored to meet patients’ needs.
  • Governance systems were operated including quality improvement initiatives.
  • The practice was engaged in local initiatives and worked effectively alongside partners in the local healthcare system.

Whilst we found no breaches of regulation the provider should:

  • Continue to review outcomes for patients diagnosed with long term conditions.
  • Evaluate the change in consent procedures to confirm the new system is operated effectively.
  • Review the new process reminder process for cervical cytology testing with a view to increasing uptake.

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










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