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Inspection summaries and ratings from previous provider

Overall summary & rating

Requires improvement

Updated 19 June 2019

  • Recruitment checks needed to be strengthened, particularly in respect of locum staff working at the practice.
  • An effective fail-safe system was not in operation for the receipt of cytology results.
  • Not all clinical staff were able to provide us with assurance about their engagement with safeguarding processes.
  • Action plans for infection control audits and fire risk assessments needed documented evidence of follow up actions being completed in a timely manner.

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

  • The practice did not always have sufficient systems to identify, manage and mitigate risk.
  • We found that the oversight of some systems required additional assurances to ensure they were working effectively.

We rated the practice as good for providing effective, caring and responsive services, and for all population groups because:

  • Patients received effective care and treatment that met their needs.
  • Staff treated patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way. The practice organised and delivered services to meet their patients’ needs.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the specific details on action required at the end of this report).

In addition, the provider should:

  • Consider their approach to clinical audit to develop consistency and clear evidence of their impact on the outcomes achieved for patient care
  • Ensure staff training is monitored closely and records are updated. Staff should be encouraged to undertake a wide range of training modules to support wider team development.

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


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