You are here

Inspection Summary

Overall summary & rating


Updated 20 January 2020

We carried out an announced full comprehensive inspection at The Belgravia Surgery on 21 November 2019 as part of our inspection programme.

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change (either deterioration or improvement) to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well led?

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 providing safe, caring, responsive and well led services because:

  • People had good outcomes because they received effective care and treatment that met their needs.
  • Information about people’s care and treatment was routinely collected, monitored and acted upon.
  • The practice organised and delivered services to meet patients’ needs. 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-centre care.
  • Clinical and internal audit processes functioned well and had a positive impact in relation to quality governance.

We have rated this practice as requires improvement for providing effective services because:

  • Childhood immunisation rates were below the target figure set by the World Health Organisation
  • Cervical cancer screening rates were below the target figure set by Public Health England
  • We found instances of low achievement and/or high exception reporting rates in the management of long-term conditions (Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate.)

We rated the population groups for older people, people with long-term conditions, people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia) as good and the population groups for families, children and young people and working age people (including those recently retired and students) as requiring improvement.

The areas where the provider should make improvements are:

  • Ensure that a DBS policy is in place and risk assessments where the practice decides not to carry out a check on a staff member. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Ensure that a process is in place to correctly sign Patient Group Directives. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment).
  • Review arrangements in respect of systems to ensure that safety alerts are acted upon and deliver improved outcomes for patient health.
  • Consider ways to ensure that child immunisation rates meet World Health Organisation targets
  • Consider ways to ensure that cervical screening rates meet Public Health England targets.
  • Ensure that all staff receive regular appraisals.

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






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