Archived: Eyam Surgery

We carried out an announced, focused inspection at Eyam Surgery on 29 April 2021. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: safe, effective and well-led. Due to assurances we received from our review of information, we carried forward the ratings for the following key questions: caring and responsive from our last inspection in August 2019. Overall, the practice is rated as Good. It is rated as good in safe, effective, caring and well-led and outstanding in responsive.

Following our previous inspection on 13 August 2019, the practice was rated requires improvement overall and for key questions safe and well-led. It was rated good for key questions effective and caring and outstanding in responsive. A warning notice in relation to good governance was issued. We carried out an unrated inspection at Eyam Surgery on 13 November 2019 to ensure that the issues identified in the warning notice had been addressed. We found that the provider had satisfactorily addressed the issues identified in the warning notice.

The full reports for the previous inspections can be found by selecting the ‘all reports’ link for Eyam Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a focused inspection to follow up on:

• Breaches in Regulations relating to safe care and treatment and good governance.
• Three best practice recommendations:
• Provide clear evidence and assurance that all safety alerts are received and acted upon.
• Consider the approach to how new and revised guidance, including National Institute for Health and Care Excellence (NICE) is reviewed collectively by the clinical team, for example via an established clinical audit programme.
• Review staff induction programmes to ensure this incorporates all the necessary information, training and competencies.
• Since our previous inspection, the provider’s legal identity has changed from a single-handed provider to a partnership. The regulatory history and ratings have been carried over to the new provider.

How we carried out the inspection.

Throughout the COVID -19 pandemic the Care Quality Commission (CQC) has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the COVID-19 pandemic, and in order to reduce risk, we have conducted our inspection 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 prior to the on-site inspection.
• Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider.
• Remotely reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short on-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 outstanding for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Systems had been put in place for safe staff recruitment and staff immunity to healthcare associated infections, receipt of cervical screening results, the internal distribution of prescription stationery, staff induction and the review of National Institute for Health and Care Excellence (NICE) guidance.
• Actions plans had been put in place, where required, and there was evidence that actions had been completed within a timely manner.
• The practice had appropriate systems in place for processes relating to the dispensary.
• Patients received effective care and treatment that met their needs.
• The practice had 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-centre care.
• There was clinical and managerial oversight of processes regarding patient safety. Recent safety alerts were reviewed and acted on however, we found that two historic alerts had not been acted on. The provider introduced a system to act on historic alerts before the end of our inspection.

Whilst we found no breaches of regulations, the provider should:

• Embed into practice the newly developed system of updating existing alerts onto the records of children with a child protection plan in place and adding alerts to the records of vulnerable adults, as identified at the multidisciplinary meetings.
• Embed into practice the newly developed tool to demonstrate formal, clinical oversite of the practice nurse’s consultations and prescribing.
• Continue to develop and implement the newly developed electronic system to support the ongoing review of historic Medicines and Healthcare products Regulatory Agency (MHRA) alerts.

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