Archived: MKGP Roysia Surgery

We carried out an announced comprehensive inspection at MKGP Roysia Surgery on the 28 March 2022.

We have rated this practice good overall.

Safe – Good

Effective – Good

Caring – Good

Responsive – Good

Well-led - Good

This is the first inspection of MKGP Roysia Surgery under the registered provider MKGP Plus Limited. MKGP Plus Limited became the provider of MKGP Roysia Surgery from March 2021. When this service registered with us, it inherited the regulatory history and ratings from its predecessor.

We had previously inspected Roysia Surgery under the previous provider and published our report dated 11 January 2017. At that inspection we rated the practice good overall, and good in all domains.

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

Why we carried out this inspection

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Cambridgeshire and Peterborough. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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.
• The practice had a comprehensive programme of quality improvement activity in place.
• Staff worked together and with other organisations to deliver care and treatment.
• 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 need of patients during the COVID-19 pandemic.
• The practice had recruited additional staff and had an active recruitment plan.
• Feedback from staff was positive about practice level management, but not all staff understood the vision, values and strategy of the organisation.

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

• Clarify roles and responsibilities between the central HR function and practice management team.
• Undertake a review of all policies to ensure the monitoring of their effectiveness is considered.
• Strengthen the system for managing Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts.
• Continue to ensure patients long term conditions needs are assessed in line with national guidance.
• Establish a system to assure the competencies of all staff employed in the practice.
• Consider the views of staff, patients and external partners when developing a clear vision and strategy.
• Ensure all staff have access to a Freedom to Speak Up Guardian.
• Continue with plans to include the views of patients in future planning and improvements through an active Patient Participation Group.

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