We carried out an comprehensive inspection at The Molebridge Practice North Leatherhead Clinic on between 6 and 13 June 2023. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring – Good
Responsive – Good
Well-led - Good
Following our previous inspection in June 2019 the practice was rated Requires Improvement overall and for the key questions Safe, Effective and Well -led. Since the last inspection the provider has changed twice.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Molebridge Practice North Leatherhead Clinic on our website at www.cqc.org.uk
Why we carried out this inspection
The practice had been previously rated as Requires Improvement in June 2019. This inspection was to follow up breaches of regulations 12: Safe care and treatment, 17: Good governance, 18: Staffing and 19: Fit and proper persons employed as identified in our previous 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 facilities.
- 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 to the main surgery and the branch surgery.
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 had clear systems, practices and processes to keep people safe and safeguarded from abuse.
- There were adequate systems to assess, monitor and manage risks to patient safety.
- The practice had systems for the appropriate and safe use of medicines, including medicines optimisation and high risk medicines.
- 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- There were evidence of systems and processes for learning and continuous improvement.
- Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
- There was an effective system for recording and acting on safety alerts.
- Test results were followed up appropriately in order to diagnose long-term conditions. For example, diabetes.
- There were comprehensive and well managed records to demonstrate that staff recruitment checks had been carried out in accordance with regulations for all staff.
- Arrangements for chaperoning were effectively managed.
- There were processes to assess the risk of, and prevent, detect and control the spread of infection.
- Staff immunisation status was effectively monitored.
- There were effective governance and monitoring processes to ensure the safety of premises.
- Fire safety processes were in place and well documented, including staff participation in fire drills.
We saw the following noteable practice:
The practice was providing services for the local community and not just its patients. We noted several projects the practice had taken part in that benefited their patients and the wider community. For example:
- Pop-up COVID19 vaccination clinics for those in the community that were unable to attend the clinic at Epsom racecourse. This included a pop-up clinic in a traveller’s church.
- Links with local community providers such as Leatherhead Community Hub which housed the food bank, the community fridge, a café, subsidised craft, and well-being activities.
- Work Experience and Enrichment Projects with Local Schools.
- Improving care for patients with substance misuse.
- Patient drop in sessions with a Health & Well-Being coach and social prescribers (funded by the Primary Care Network).
Whilst we found no breaches of regulations, the provider should:
- Review and continue to monitor cervical screening to meet the UK Health and Security Agency uptake target.
- Continue to take action to develop the patient participation group.
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