27 April 2022
During an inspection looking at part of the service
We carried out an announced inspection at The Drayton Surgery on 27 April 2022. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring – Good (Carried over from the previous inspection)
Responsive - Good (Carried over from the previous inspection)
Well-led - Good
Following our previous inspection in November 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 The Drayton Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection focused on the key questions of Safe, Effective and Well-led. We also reviewed access arrangements following changes made during the COVID-19 pandemic. We carried forward the rating of Good for caring and responsive from the previous inspection.
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 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
- Inviting staff to complete and submit a questionnaire.
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:
- 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.
- 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-centred care.
We found no breaches of regulations.
The provider should:
- Continue to embed infection prevention and control procedures, including completing annual audits and any actions required and recommended from the audits.
- Continue to monitor and ensure staff complete mandatory training set by the practice
- Restart the 2022 appraisal programme
- Continue to implement the new safety alert log, replacing their current system
- Continue to promote cervical screening to achieve the 80% target
- Explore effective communication strategies that meet the needs of all staff to ensure they are aware of changes at the practice
- Resume regular meetings for different staff groups.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care