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Inspection Summary

Overall summary & rating


Updated 30 August 2021

We carried out an announced review at Luson Surgery on 22 June 2021. Overall, the practice is rated as good.

Following our previous inspection on 11 December 2019 the practice was rated Good overall and for all key questions, except for the effective key question and the long-term condition, working age people and people experiencing poor mental health population groups which were rated as requires improvement.

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

Why we carried out this review

This was a follow up review of concerns identified in the 2019 inspection.

The focus of this review was:

  • To review the services provided to people with long-term conditions and the outcomes for these patients using the Quality and Outcomes Framework (QOF) performance.
  • To review the services provided to Working age people (including those recently retired and students).
  • To review the services provided to people experiencing poor mental health the outcomes for these patients using the Quality and Outcomes Framework (QOF) performance.

How we carried out the review

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 reviews differently.

This review was carried out off site. This was with consent from the provider and in line with all data protection and information governance requirements.

Our approach included:

  • Conducting staff interviews using tele-conferencing
  • Reviewing performance data available at the time of our inspection.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we undertook the review
  • 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 of the population groups.

We found that:

  • Patients with long-term conditions and people experiencing poor mental health had their needs assessed and their care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • Throughout the pandemic, patients with long-term conditions were recalled as appropriate. Patients were proactively contacted using text messages and through personal contact from healthcare assistants and clinical staff. Patients were opportunistically contacted to carry out reviews.
  • Childhood immunisation and cervical screening data was below expected national targets for some indicators but the practice had an action plan in place to target and work with individuals who declined these services to better understand the rationale of patient choice.
  • Work had been undertaken to increase the completion of care reviews for those patients diagnosed with cancer.
  • Face-to-face appointments were offered when clinically necessary.
  • The practice worked in a multidisciplinary manner to ensure that patient needs were met. Staff worked proactively with the local Primary Care Network (PCN) to increase access to a range of services, including access to health coaches and mental health practitioners.

Whilst we found no breaches of regulations, the provider should:

  • Continue to monitor and improve care for patients with diabetes and frailty.
  • Continue to take action to increase the uptake of cervical screening.
  • Continue to take action to increase the uptake of childhood immunisations.

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