21 July 2023
During a routine inspection
We carried out an announced comprehensive inspection at Maidstone Road Surgery on 21 July 2023. Overall, the practice is rated as good.
The ratings for each key question are:
- Safe - good
- Effective - good
- Caring - good
- Responsive - good
- Well-led - good
The full comprehensive report can be found by selecting the 'all reports' link for Maidstone Road Surgery on our website at www.cqc.org.uk.
Why we carried out this inspection:
We carried out an announced comprehensive inspection at Maidstone Road Surgery on 21 July 2023 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
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:
- Requesting evidence from the provider.
- A site visit.
- Completing clinical searches on the practice's patient records system in line with all data protection and information governance requirements.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
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.
- Information from the provider, patients, the public and other organisations.
We found that:
- The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
- Appropriate standards of cleanliness and hygiene were met.
- Staff had the information they needed to deliver safe care and treatment.
- The practice had systems for the appropriate and safe use of medicines, including medicines optimisation.
- The practice learned and made improvements when things went wrong.
- Patients' needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
- The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
- Staff had the skills, knowledge and experience to carry out their roles.
- Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
- The practice organised and delivered services to meet patients' needs.
- People were able to access care and treatment in a timely way.
- Complaints were listened and responded to and used to improve the quality of care.
- There was compassionate, inclusive and effective leadership at all levels.
- The practice had a culture which drove high quality sustainable care.
- There were clear responsibilities, roles and systems of accountability to support good governance and management.
- There were clear and effective processes for managing risks, issues and performance.
- The practice involved the public, staff and external partners to sustain high quality and sustainable care.
Whilst we found no breaches of regulations, the provider should:
- Continue with plans to offer relevant vaccination boosters to staff who require them.
- Consider revising medicines management so that all action taken by staff when breaches of the cold chain are identified is recorded to help demonstrate vaccines remain safe to use.
- Continue improving uptake of childhood immunisations where required.
- Continue to add relevant regulated activities to the provider registration with CQC.
Dr Sean O'Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care
Please refer to the detailed report and the evidence tables for further information.