Archived: Drybrook Surgery

We carried out an announced inspection at Drybrook Surgery on Friday 13 May 2022. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective - Requires Improvement

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection on 28 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 Drybrook Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to review the standard of care since our previous report.

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
• 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:

• The practice had just gone through a change in management and ownership. There was a lack of clarity on allocation of a new registered manager. The practice had submitted an application to put these leads in place but withdrew the application prior to processing in January 2022. At the time of the inspection the practice had not resubmitted their applications for a new registered manager or provider.
• There was evidence of some audit activity carried out by the practice. However, there was no formal quality improvement programme in place.
• Systems and processes to monitor significant event occurrences were ineffective.
• There was limited evidence of learning and dissemination of information for the management of incident reporting.
• The systems in place for monitoring patients’ health in relation to the use of medicines including high risk medicines, were ineffective.
• There was limited evidence for established quality improvement process. The practice was not participating in any local or national clinical pilots or other initiatives.
• We found that the Infection prevention and control was not given sufficient priority or oversight.
• People were able to access care and treatment in a timely way.
• The practice understood the needs of its local population and had developed services in response to those needs.
• Staff treated patients with kindness, respect and compassion.
• Patient feedback was positive about the care and treatment they had received.
• Governance systems and processes were in place but not fully embedded into practice.

We found breaches of regulations. The provider must:

• Ensure incidents are effectively recognised and reported and acted upon.
• Ensure infection prevention and control is formally documented with adequate time and resource to ensure compliance.
• Establish effective processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Develop an effective system for monitoring patients’ health in relation to the use of medicines including high risk medicines and those with long term conditions have adequate oversight.
• Develop and implement a quality improvement process and rolling audit plan.

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