Clayton Brook Surgery

We carried out an announced inspection at Clayton Brook Surgery on 26 May 2022. Overall, the practice is rated as Good with the following key question ratings:

Safe – Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Why we carried out this inspection

This was a full comprehensive inspection due to changes to the registration of the practice.

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 remotely and on site.
• 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
• Staff completing questionnaires.
• 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.

However, we rated the practice as Requires Improvement for providing safe services because:

• Although we found that most clinical areas of service were delivered, we found that systems and processes in place to manage risk within the practice were not working effectively or as intended.
• Safeguarding alerts were not consistently recorded on the patient record.
• The clinical record when a high risk medication review or a review of patients with a long-term condition had taken place was not fully documented.
• There were no processes for acting on safety alerts, in particular historic alerts, to minimise the risk of any patients not receiving the monitoring required for the medicines they are prescribed.

For the key questions caring, effective, responsive and well led we found that:

• 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 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.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

In addition the provider should:

• Continue to catch up on medication reviews for patients where recall has lapsed due to the pandemic.
• Monitor the system implemented in relation to patients with diabetes, making sure these are embedded and maintained.
• Work towards improving levels of cervical screening.

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