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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



Updated 24 May 2016

The practice is rated as good for providing safe services.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated to all relevant staff to support improvement.

  • Information about safety was recorded, monitored appropriately, reviewed and addressed. Safety issues and significant events were routinely discussed during weekly meetings.

  • Risks to patients were assessed and well managed and these were re-visited regularly or when circumstances changed.

  • There was a recruitment policy and procedure in place to ensure patients safety was protected. We found that senior staff had adhered to the policy and procedure.

  • Staffing levels were regularly monitored to ensure there were enough staff to keep people safe and arrangements were in place to improve the numbers of clinical staff.


Requires improvement



Updated 24 May 2016

The practice is rated as good for providing caring services.

  • Staff ensured that patients’ dignity and privacy were protected and patients we spoke with confirmed this.

  • Patients had their needs explained to them and they told us they were involved with decisions about their treatment.

  • We saw that staff treated patients with kindness and respect and maintained confidentiality.

  • Information for patients about the services available to them was easy to understand and accessible.

  • We observed a patient-centred culture and feedback from patients about their care and treatment was positive. Patients told us they were satisfied with the standards of care they received.

  • Data published in January 2016 from the national patient survey gave below average results for caring. All patients we spoke with on the day were complimentary about their care. The practice manager told us the demographics of the registered patients may have affected the results.

  • Carers were encouraged to identify themselves. Clinical staff provided them with guidance, signposted them to a range of support groups and ensured their health needs were met. The community champion system also provided assistance in this area. Staff who had been trained circulated with patients during busy periods and offered non-clinical advice and support.



Updated 24 May 2016

The practice is rated as good for providing responsive services.

  • Most patients told us it was easy to make an appointment and urgent appointments were available the same day. Some patients told us they sometimes had difficulties in getting appointments when they felt they needed them. Regular patient surveys were carried out to review and improve the appointments system.

  • There was a shortage of GPs. Senior staff were seeking to recruit a GP and more nursing staff and to change the way nurses worked to compensate.

  • The practice provided enhanced services. For example, avoiding unplanned admissions by carrying out health reviews and development of individual care plans. Patients were reviewed within three working days of their hospital discharge.

  • Information about how to complain was available and easy to understand. Leaflets were available for patients to take away to record their complaint details.

  • Evidence showed that senior staff responded quickly and appropriately when issues were raised. Where necessary apologies were provided and improvements made.

  • Learning from complaints was shared with all staff and other stakeholders to prevent recurrences.


Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people

Requires improvement

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