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Elbury Moor Medical Centre Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 6 December 2019

We carried out an inspection of this service on 17 October 2019 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 to the quality of care provided since the last inspection.

This inspection focused on the following key questions: Effective and Well-led.

In view of the assurance received from our review of information, we carried forward the ratings for the following key questions: Safe, Caring and Responsive.

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 requires improvement overall and good for all population groups with the exception of families, children and young people and working age people (including those recently retired and students).

We rated the practice as requires improvement for providing effective and well-led services because:

We found that:

  • The practice’s uptake of the childhood immunisations rates was below the national averages for all of the four immunisations measured.
  • The practice’s uptake of the national screening programme for cervical cancer was below the local and the national averages.
  • Data showed higher than average quality and outcomes framework (QOF) exception reporting and inconsistencies in the practice processes.
  • Risks to patients were assessed and well managed.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was a clear leadership structure and staff felt supported by the management.
  • Leaders did not always have a clear picture of performance and systems of review and audit had not been effectively implemented.
  • The practice had demonstrated good governance in most areas, however, they were required to make further improvements.
  • The practice had already identified and taken steps to address many of the issues raised during our inspection but as actions had been recent and they were unable to demonstrate the impact or effectiveness.

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

  • Continue to work on reducing the prescribing of hypnotics and antibiotics.
  • Continue work to increase the uptake for cervical, breast and bowel screening.
  • Continue with actions to increase the uptake for immunisations.
  • Continue to take actions to improve performance and ensure patients receive care and treatment that meets their needs.
  • Continue to take steps to increase an audit programme of quality improvement.

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






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