• Doctor
  • GP practice

Glemsford Surgery

Overall: Good read more about inspection ratings

Glemsford surgery, Lion Road, Glemsford, Sudbury, CO10 7RF (01787) 280484

Provided and run by:
West Suffolk NHS Foundation Trust

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Date of Assessment: 12 June 2025 to 17 June 2025. Glemsford Surgery is a GP practice and delivers a service to 4666 people under a contract held with NHS England. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the practice, 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: The practice had a good learning culture and people could raise concerns. Leaders at the practice investigated incidents thoroughly. We found people were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks were mitigated. There were staff with the right skills, qualifications and experience working at the practice. Leaders made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

EFFECTIVE: People told us they were involved in assessments of their care and treatment. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with stakeholder healthcare providers involved in people’s care, for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to provide informed consent. Staff ensured decisions were made in people’s best interests where they did not have capacity.

CARING: People told us they were treated with kindness and compassion. Staff protected people’s privacy and dignity. They treated them as individuals and supported their preferences. People were provided choices about their care and treatment. The practice supported their staff members wellbeing.

RESPONSIVE: People were involved in decisions about their care. The practice provided information in a format that people could understand. People knew how to provide feedback to the practice and felt the practice would act on it. The practice had worked to eliminate discrimination to access the environment. People told us they received appropriate care and treatment. The practice worked to reduce health and care inequalities through educational materials in the waiting room, staff training and feedback. People were involved in planning their care and understood options around choosing to receive or not receive care and treatment.

WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff to develop in their roles. Staff told us they felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities within the practice. Leaders worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement and staff were given time and resources to innovate and improve.

20 August 2022

During a routine inspection

We carried out an announced inspection at Glemsford Surgery on Wednesday 20 July 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe – Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

When this provider, West Suffolk Foundation Trust (WSFT) registered Glemsford Surgery location with CQC, they inherited the regulatory history and ratings of the predecessor. This is the first inspection of Glemsford Surgery under the registered provider WSFT who became the provider from May 2020.

Following our previous inspection of the predecessor location on 01 November 2016, the practice was rated Good overall and for all key questions:

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Glemsford Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive first inspection to rate a new location.

This included:

  • Inspection of the key questions:
    • Safe
    • Effective
    • Caring
    • Responsive
    • Well-led

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

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

We found that:

  • We found patients with safeguarding identified had been discussed in safeguarding meetings however, we found no alerts on some patient’s records.
  • The practice lacked a process to review historical MHRA alerts effectively. We found some medicine reviews hadn’t identified the safety alerts for the medicines prescribed.
  • The practice had effective systems to ensure all emergency medicines and equipment were safe to use.
  • We found some patients taking high risk medicines lacked consistent monitoring.
  • We found some patients that had potential missed diagnosis of diabetes and chronic kidney disease. We also found some blood test results used when reviewing and monitoring some patients with long term conditions were out of date.
  • Staff competency monitoring was carried out on a daily basis; however, this was not formally documented, and lacked the clinical oversight to ensure high risk drug monitoring was effective.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice respected patients’ privacy and dignity and patient confidentiality was maintained throughout the practice
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care, however some systems and processes introduced during or following our inspection needed to be embedded.

We found a breach of regulations. The provider must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

  • Continue to embed the process to monitor the appropriate level of antibiotic prescribing for uncomplicated urinary tract infections.
  • Continue to review and improve the opportunities for patients to access health screening checks.
  • Continue to engage in patient feedback/survey exercises to gain and act upon patient opinion to improve patient satisfaction.

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