During an assessment under our new approach
Date of Assessment: 23 July 2026. Abbey Surgery is a GP practice and delivers services to approximately 15,000 people under a contract held with NHS England. The service has a main site and a branch site. According to the latest available data, the ethnic make-up of the service area is approximately 98% White, 0.5% Asian, 1% Mixed, less than 1% Black and less than 1% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 7th decile (7 of 10). The lower the decile, the more deprived the service population is relative to others.
The service has dispensing facilities for people who live more than a mile away from a dispensing chemist. A delivery driver is available to ensure medicines reach isolated people who use the service.
This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. 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.
Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. There were enough staff with the right skills, qualifications and experience. However, the service was not following national infection prevention and control guidance consistently. Not all staff were up to date with training which the service had deemed mandatory and recruitment processes were not in line with regulatory requirements.
Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.
Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity.
People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.
The service had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities. Leaders accounted for the actions, behaviours and performance of staff through clear and effective governance processes. However, the service did not consistently ensure effective oversight of infection prevention and control; control of potential risks in the care environment; completion of mandatory training; and safe recruitment.
We found a breach of regulations in good governance. Systems and processes to underpin the running of the service were not effective. We have asked the provider for an action plan in response to the concerns found at this assessment.