Cumberland House

Updated 3 July 2026

Date of Assessment: 13 July 2026. Cumberland House Surgery is a GP practice and delivers services to approximately 9,453 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 96% White, 1.6% Asian, 1.5% Mixed, 0.4% Black and 0.4% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 9th decile (9 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

Safe: Facilities and equipment met people's needs and were clean and well-maintained, and there were enough staff with the right skills, qualifications and experience.We identified areas where the provider's documented systems for overseeing safety were not always effective. This included the lack of relevant risk assessments and limited evidence when risks had been identified, mitigating action had been taken, recruitment documentation including vaccination status, documentation of formal clinical supervision, mandatory training and prescription safety and tracking. These findings reflected weaknesses in governance and documented oversight, no evidence of patient harm was identified. The underlying governance issues were addressed under the Well-led key question and the associated Regulation 17, Good Governance breach.

Effective: Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.

Caring: Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity. The feedback we received from people who used the service was overwhelmingly positive.

Responsive: People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.

Well-led: We found that the provider did not have effective governance systems in place to ensure consistent oversight of safety, quality and performance. The practice had a positive culture, and staff were committed to providing safe care. We identified issues with risk assessments, recruitment documentation including vaccination status, documentation of formal clinical supervision, mandatory training and prescription safety and tracking, as set out under the Safe and Well-led key questions of this report. We identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to submit an action plan within 28 days to address the concerns identified during this assessment.

Updated 3 July 2026

As part of our assessment, we reviewed feedback from people who used the service to understand their views and experience of the service. This included reviewing feedback received through our Give Feedback on Care service. People were consistently positive about the kindness, compassion and emotional support provided by both clinical and non-clinical staff. They told us care and treatment appeared coordinated, with evidence of proactive monitoring of long-term conditions and effective use of the wider multidisciplinary team. People described staff as caring, respectful, professional, approachable and supportive, and the service provided as ‘excellent’, ‘gold star’, ‘professional, caring and friendly’, and ‘efficient and supportive’.

People were positive about the quality of their care and treatment. They described how staff treated them with kindness and compassion and respected their privacy. This was mirrored in the results of recent surveys, including the 2025 National GP Patient Survey, which showed the people were satisfied. For example, 86% of respondents were positive about their overall experience of the GP practice, in line with the national average of 75%. Since the inspection, GPPS have published new results in July 2026. The new data suggests a slight improvement with 87% of people responding positively.

The practice was working alongside the patient participation group (PPG) to further develop the group and expand membership, to better represent the views of people using the service. To improve diversity and inclusion, the practice had created a virtual group in addition to the physical group. A representative of the PPG was complimentary about the practice and the changes being made.