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Inspection Summary

Overall summary & rating


Updated 12 December 2019

This inspection was an announced comprehensive inspection, which we undertook on 7 November 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

We decided to undertake an inspection of this practice following their registration to carry out regulated activities in October 2018.

This report covers our findings in relation to those requirements.

The practice was rated good for all key questions and all population groups. 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 and the public.

We rated the practice as good for providing safe services because:

  • All necessary recruitment checks including references had been undertaken for staff.
  • Staff who carried out chaperoning had received training and were aware of their responsibilities.
  • There was evidence of lessons learned and improvements made when things went wrong.

We rated the practice as good for providing effective services because:

  • Patients received effective care and treatment that met their needs.
  • Staff are supported to deliver effective care and treatment, including through meaningful and timely supervision and appraisal.
  • The practice participated in relevant local and national clinical audits and other monitoring activities such as reviews of services and benchmarking.

We rated the practice as good for providing caring services because:

  • Thirty-two CQC comment cards received, 27 were wholly positive about the care and treatment received at the practice.
  • We observed staff treating patients with respect and dignity.

We rated the practice as good for providing responsive services because:

  • The practice had reviewed the needs of the population and responded accordingly.
  • Feedback from patients led to a new telephone system, and complaints were responded to appropriately and within the practice’s timeframe.
  • Shared care agreements were in place to ensure patient treatment was coordinated.

We rated the practice as good for providing well-led services because:

  • Governance of the practice assured the delivery of high-quality and person-centred care, supported learning and innovation, and promoted an open and fair culture.
  • Staff understood the practice’s vision, values and strategy, and their role in achieving them.
  • Arrangements with partners and third-party providers were governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care.

The areas where the provider should make improvements:

  • Provide appropriate support for patients who are bereaved.
  • Put appropriate tools in place to assist patients in describing and rating their pain intensity and to monitor the effectiveness of pain interventions.

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