We carried out a review of the data available to us about College Street Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about College Street Medical Practice, you can give feedback on this service.
We carried out a desk-top focused review at College Street Medical Practice on 16 March 2020.
The practice previously had a comprehensive inspection in November 2016 when it received an overall rating of good, although the caring domain was rated as requires improvement. All population groups were rated as good with the exception of people experiencing poor mental health (including those with dementia) which was rated as requires improvement. This was due to some QOF indicators for mental health being lower than local and national averages, and some areas of exception reporting for mental health QOF indicators being higher than averages.
The practice received a focused inspection in August 2017 to review the caring domain and remained rated as requires improvement for providing caring services with an overall rating of good. A further focused inspection took place in September 2018 at which the practice was rated as good for providing caring services. However, the population group of people experiencing poor mental health (including those with dementia) was not reviewed at either of these two inspections and therefore the published rating was still listed as requires improvement for this population group.
This was highlighted at the practice’s Annual Regulatory Review in February 2020, and it was agreed to undertake a desk-top focused inspection to review the population group for people experiencing poor mental health (including those with dementia).
We undertook this desk based review on 16 March 2020 to check that the provider had completed the areas identified as requiring improvement. We did not visit the practice as part of this inspection.
This report only covers our findings in relation to the population group for people experiencing poor mental health (including those with dementia). You can read the report from our last comprehensive inspection and the subsequent focused inspections, by selecting the 'all reports' link for College Street Medical Practice on our website at
The practice remains rated as good overall; the population group of people experiencing poor mental health (including those with dementia) is also now rated as good. This was because:
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
We carried out an announced comprehensive inspection at College Street Medical Practice on 13 August 2015. The overall rating for the practice was requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.
We carried out a second announced comprehensive inspection at College Street Medical Practice on 15 November 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for this practice following the second inspection was good.
However the practice was rated requires improvement for providing caring services.
The full comprehensive reports can be found by selecting the ‘all reports’ link for College Street Medical Practice on our website at www.cqc.org.uk.
We carried out an announced focused inspection on 9 August 2017 to assess improvements made in the area of ‘Caring’. The practice remained rated as requires improvement for providing caring services.
This inspection was an announced focused inspection carried out on 17 September 2018 to review actions taken by the practice since our previous inspection in August 2017. This report covers our findings in relation to actions taken by the practice since our last inspection in the area of ‘Caring’.
Overall the practice remains rated as ‘Good’. The practice is now also rated ‘Good’ for providing caring services.
Our key findings were as follows:
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at College Street Medical Practice on 13 August 2015. The overall rating for the practice was requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.
We carried out a second announced comprehensive inspection at College Street Medical Practice on 15 November 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for this practice following the second inspection was good. However the practice was rated requires improvement for providing caring services.
As a result of this rating an announced focused inspection took place on 9 August 2017 to assess the improvements made to the caring key question. The practice is rated as requires improvement for providing caring services.
Our key findings were as follows:
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at College Street Medical Practice on 13 August 2015. The overall rating for the practice was rated as requires improvement and the practice was asked to provide us with an action plan to address the areas of concern that were identified during our inspection.
We carried out a second announced comprehensive inspection at College Street Medical Practice on 15 November 2016 in order to assess improvements and the outcomes from their action plan. The overall rating for this practice following the second inspection is now good.
Our key findings were as follows:
There was an open and transparent approach to safety within the practice. Effective systems were in place to report, record and learn from significant events. Learning was shared with staff and external stakeholders where appropriate.
Risks to patients were assessed and well managed.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Patients were recalled to ensure care was in keeping with best practice.
Training was provided for staff which equipped them with the skills, knowledge and experience to deliver effective care and treatment.
Patients said they were treated with compassion and dignity, and staff were supportive and respectful in providing care, involving them in care and decisions about their treatment.
Patients told us they were usually able to get urgent appointments on the same day with a clinician when they needed one; however it was not easy to get appointments with a named GP.
Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns and learning from complaints was shared with staff and stakeholders.
The practice had good facilities and was well equipped to treat patients and meet their needs. Services were designed to meet the needs of patients.
There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
However, there were also areas of practice where the provider should consider improvements.
Continue to review and take steps to address areas of lower patient satisfaction feedback.
Maintain a log of medicines alerts received and acted on.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at College Street Medical Practice on 13 August 2015. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
Staff understood and fulfilled their responsibilities to raise significant events and safeguard patients from abuse. All opportunities for learning from internal and external incidents were maximised.
Some risks to patients were assessed and well managed, with the exception of those relating to the environment, infection control and management of the service.
Most patients’ needs were assessed and care was planned and delivered following best practice guidance.
Data reviewed showed the majority of patient outcomes were comparable to the local and national averages.
Staff worked closely with other services to ensure that patients’ needs were met.
The majority of patients said they were treated with compassion, dignity and respect and felt they were involved in their care and decisions about their treatment.
Information about how to complain was available and easy to understand.
There was a clear leadership structure and most staff felt supported by management.
However there were areas of practice where the provider needs to make improvements.
The areas where the provider must make improvements are:
Ensure the implementation and regular review of formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
Ensure notifiable incidents are reported to the Care Quality Commission.
The provider should also:
Improve the availability of non-urgent appointments and continuity of care for patients.
Ensure recruitment arrangements include all necessary employment checks for all staff.
Carry out re-audits to improve patient outcomes and clinical audits related to minor surgery.
Ensure all staff are fully supported with formal induction and training relevant to their role.
Chief Inspector of General Practice