The Care Quality Commission
  • Doctor
  • GP practice

Cantilupe Surgery

Overall: Good read more about inspection ratings

51 St Owen Street, Hereford, Herefordshire, HR1 2JB (01432) 268031

Provided and run by:
Cantilupe Surgery

All Inspections

6 December 2023

During an inspection looking at part of the service

We carried out an announced focused assessment of the responsive key question at Cantilupe Surgery at on 6 December 2023. The rating for the responsive key question is Good. As the other domains were not reviewed during this assessment, the rating of good will be carried forward from the previous inspection and the overall rating of the service will remain Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good.

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

Why we carried out this inspection.

We carried out this inspection to undertake a targeted assessment of the key question of responsive.

How we carried out the inspection

This inspection was carried out remotely.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting evidence from the provider.

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 found that:

  • The practice understood the needs of its local population and tailored services to meet those needs.
  • The practice continuously audited and adjusted services based on patient demand to support patients to access appropriate care.
  • The practice worked effectively with local partners to improve access to services for the wider patient population.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

12/02/2019

During a routine inspection

We carried out an announced comprehensive inspection at Cantilupe Surgery on 12 February 2019 as part of our inspection programme. The practice was previously inspected on 15 October 2014 and rated good overall.

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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse and for identifying and mitigating risks of health and safety.
  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines and best practice.
  • Patients’ needs were assessed and care delivered in line with current guidelines. Staff had the appropriate skills, knowledge and experience to deliver effective care and treatment.
  • Staff treated patients with kindness and respect and involved them in decisions about their care.
  • Patient feedback from the national GP patient survey was positive with all results above local and national averages.
  • Urgent same day patient appointments were available when needed. All patients who completed comment cards told us they were always able to obtain same day appointments and access care when needed.
  • There was an open and transparent approach to safety and a system in place for recording, reporting and learning from significant events. The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • There were clear responsibilities, roles and systems of accountability to support effective governance.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

Whilst we found no breaches of regulations, the provider should:

  • Take action to ensure that the risk assessment for the premises was kept under review so that staff could feel confident that details were up to date at all times.
  • Review the system to ensure that all staff receive safeguarding training suitable for their role.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

15 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected this service on 15 October 2014 as part of our new comprehensive inspection programme. Cantilupe Surgery has a branch surgery but we did not inspect this at this time.  

The overall rating for this service is good.  We found the practice to be good in the safe, effective, caring, responsive and well-led domains.  We found the practice provided good care to care to older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people in vulnerable circumstances and people experiencing poor mental health. 

Our key findings were as follows:

  • Patients were kept safe because there were arrangements in place for staff to report and learn from incidents that occurred. The practice had a system for reporting, recording and monitoring significant events over time.
  • There were systems in place to keep patients safe from the risk and spread of infection.
  • Evidence we reviewed demonstrated that patients were satisfied with how they were treated and that this was with compassion, dignity and respect.  It also demonstrated that the GPs were good at listening to patients and gave them enough time.
  • The practice had an open culture that was effective and encouraged staff to share their views through staff meetings and significant event meetings. 

We saw several areas of outstanding practice including:

  • The practice nurse was qualified and had trained to provide minor surgery for patients.  This was a timely and effective service that ensured treatments were available at the practice and that patients do not have to wait for referral appointments elsewhere.
  • There were two nurse consultants at the practice who acted independently to the GPs who prescribed, arranged investigations and referred patients to specialist doctors. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice