Uxendon Crescent surgery

We carried out an announced inspection at Uxendon Crescent Surgery on 21 April 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led - Good

The provider had become registered with the CQC in November 2020. The practice had been inspected under its previous registration in April 2019 and was rated Good.

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

Why we carried out this inspection

This inspection was the practice’s first inspection under the new provider’s registration with CQC. The inspection was a comprehensive inspection, meaning we looked at all five key questions; Safe, Effective, Caring, Responsive and Well-led.

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 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.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Patients could not always 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.

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

• Review and improve the prescribing of antibiotics to bring it in line with local and national averages.
• Review and improve their achievement in childhood immunisation and cervical screening.
• Review and improve patient experience and feedback in relation to accessing the service and using the service.

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