We carried out an announced comprehensive inspection at Totley Rise Medical Centre on 11 December 2018 as a new provider for the location had registered with the CQC in April 2018.

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.
• 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 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 promoted the delivery of high-quality, person-centre care and there was a strategy in place to improve systems and processes.

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

• Review and formalise the protocol for actioning incoming hospital letters.
• Review systems for checking the immunisation status for all staff including GPs in line with the Department of Health Immunisation Against Infectious Disease Guidance (the Green Book).
• Follow the complaints procedure and include information about how to escalate complaints in the response letter to the complainant.
• Take action to implement an overview log of actions taken as a result of medicines and safety alerts for staff to access.

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