Anlaby Surgery

We carried out an announced inspection at Anlaby Surgery on 19th – 22nd July 2022. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective – Requires Improvement

Caring – Not Rated

Responsive – Not Rated

Well-led – Requires Improvement

Following our previous inspection on 28th June 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 Anlaby Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection as part of our direct monitoring intelligence system Band 1 sampling exercise. This exercise is looking at a percentage of band 1 locations in each sector with published statements on our website as part of our quality assurance process to monitor the effectiveness of our new monitoring approach. We need assurance that Good or Outstanding rated locations are still good or outstanding and that we were right to publish the public statement.

How we carried out the inspection/review

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 Requires Improvement overall

We found that:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• 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.
• Recently senior leaders at the practice had changed and the new leadership team were making progress to the running of the practice.
• Staff reported that since the change of management the culture of the practice had improved.
• The practice did not have any formal safeguarding meetings only informal discussions
• The practice did not have any risk assessments for emergency drugs
• Systems for managing and reviewing patients with long term conditions were not effective. The majority of patients on direct oral anticoagulants (DOAC) medication had not had the required monitoring.
• The practice did not have a clear protocol for dealing with Medicines and Healthcare Products Regulatory Agency (MHRA) alerts
• There was no clear governance structure which meant systems were sometimes not reviewed
• The practice’s goverance and assurance systems were weak.

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

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 Hospitals and Interim Chief Inspector of Primary Medical Services