We carried out an announced comprehensive inspection at Eightlands Surgery on 27 and 28 July 2022. Following this inspection, we rated the location as good overall, and for all key questions:
Safe - Good
Effective - Good
Caring – Good
Responsive – Good
Well-led - Good
Why we carried out this inspection
This announced comprehensive inspection was carried out following changes to the provider registration and legal entity of the practice. This was the first inspection since this change.
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 some 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.
- Reviewing staff questionnaires.
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:
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
- There was a programme of quality improvement activity, including clinical audit.
- Staff had the skills, knowledge and experience to deliver effective care.
- Staff involved and treated people with compassion, kindness, dignity and respect.
- Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
- The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Whilst we found no breaches of regulations, the provider should:
- Continue to monitor and make improvements to increase the uptake of cervical screening.
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