Elsdon Avenue Surgery

We carried out an announced inspection of Elsdon Avenue Surgery on 8 June 2021. Overall, the practice is rated as Good.

The key questions are rated as:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Why we carried out this inspection

This inspection was a comprehensive inspection, we have carried out this inspection because the practice has reregistered with us as a new provider of GP services for this location.

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 and face to face interviews
• 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 Good overall and good for all population groups

We found that:

• The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.
• Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
• We found staff had the knowledge and skills needed to provide effective care.
• 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 practice demonstrated they had good governance processes to monitor and improve safety and safeguarding within the practice.
• There was a clear vision and strategy to deliver high quality, sustainable care.
• There were arrangements in place to support good governance and management.
• The practice learned, improved and innovated as a result of safety information and incidents.

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