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Inspection summaries and ratings from previous provider

Overall summary & rating


Updated 13 May 2019

We carried out an announced comprehensive inspection at Cotmore Surgery on 4 March 2019 as part of our inspection programme.

At the last inspection in October 2015 we rated the practice as good for providing safe, effective, caring, responsive and well-led services.

At this inspection, we found that the providers had satisfactorily moved in line with changes within the healthcare economy and had shaped the practice to sustain delivery of high-quality services.

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 good overall and good for all population groups.

We rated the practice as good for providing safe, effective, caring, responsive and well-led services because:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice scored above local and national averages in the 2018 national GP patient survey for questions relating to the care and treatment provided.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed mostly promoted the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing safe services because:

  • Staff we spoke with demonstrated how to recognise and respond to safety concerns; however, records we viewed showed not all clinical staff had completed the required training. Following our inspection, the practice provided evidence of an action plan which showed staff were required to complete fire safety training by July 2019.
  • The practice did not have a schedule in place for reviewing risk assessments for the management of Disclosure and Barring Service (DBS) checks and chaperoning.
  • Risk assessments did not adequately mitigate risks associated with not stocking some suggested emergency medicines. Following our inspection, the practice reviewed arrangements and updated their risk assessment.

The provider should:

  • Review systems and processes to ensure effective oversight of training needs and ensure that training provided satisfies published guidance and competency framework.
  • Consider the need for a formal, regular review of risk assessments relating to Disclosure and Barring Service checks and associated risk assessments to ensure risks are considered and mitigated.
  • Continue carrying out actions to improve the uptake of national screening programmes such as cervical screening.
  • Continue reviewing arrangements and updating risk assessments to determine the range of emergency medicines held at the practice.
  • Ensure a formal approach to managing significant events is established and embedded.

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








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