The Highwood Surgery

We carried out an announced comprehensive inspection at The Highwood Surgery on 11 August 2022. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires Improvement

We have not inspected this service since its registration as a new provider on 12 May 2021 following the retirement of the previous provider.

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities and to provide a rating.

We inspected all key questions: Safe, Effective, Responsive, Caring and Well-Led?

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• There were gaps in the processes for identifying patients subject to safeguarding concerns.
• The provider did not have effective recruitment systems in place.
• The provider did not have effective systems to ensure patients received structured medicines reviews.
• The provider did not have an effective system in place to prevent the reauthorisation of repeat prescriptions for patients who had not been reviewed.
• The provider did not have effective systems in place to act on patient safety alerts.
• The leadership did not ensure all clinical governance systems were operated effectively and with appropriate oversight.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.

We found a breach of regulations. The provider must:

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

The areas where the provider should make improvements are:

• Continue to embed the use of clinical audits to monitor the quality of care and improve patient outcomes.
• Continue to improve the uptake of cervical screening.
• Continue to work on embedding the practice strategy.

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