14 September 2023
During a routine inspection
We carried out an announced comprehensive inspection at Elmtrees Surgery on 14 September 2023. Overall, the practice is rated as good.
Safe - good
Effective - good
Caring - good
Responsive - good
Well-led - good
Why we carried out this inspection
We carried out this inspection because the new provider had yet to be rated since registration in March 2022. We reviewed all key questions as part of this inspection.
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:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- 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 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.
- 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.
Whilst we found no breaches of regulations, the provider should:
- Take action to ensure staff recruited by the predecessor provider have received disclosure and barring service checks at the appropriate level.
- Improve the system for maintaining records relating to staff vaccination.
- Improve the system for documenting action taken in response to safety alerts.
- Take steps to ensure fridge temperatures can be measured in line with National guidance.
- Continue to improve the systems and processes to increase childhood immunisations and cervical screening uptake.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care