Townfield Doctors Surgery

We carried out an announced comprehensive inspection at Townfield Doctors Surgery on 28 September 2022. Overall, the practice is rated as Good.

The key questions are rated as:

Safe - Good

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led - Good

Following our previous inspection on 19 August 2016, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

This was a comprehensive inspection. We carried out this inspection in response to concerns we received as part of our regulatory functions. At this inspection we covered all key questions:

• Are services safe?
• Are services effective?
• Are services caring?
• Are services responsive?
• Are services well-led?

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. At this inspection, we visited the practice which included:

• Conducting staff interviews.
• 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.

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.
• Our clinical records searches showed that the practice had an effective process for monitoring patients’ health in relation to the use of medicines including high risk medicines.
• People were not always able to 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.
• There was evidence of quality improvement activity. Clinical audits were carried out.
• The practice’s uptake of the national screening programme for cervical cancer screening and childhood immunisation uptake was below the national average.
• Annual appraisals were carried out in a timely manner.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The Patient Participation Group (PPG) was active.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

We found a breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Carry out appropriate health checks during the recruitment process.
• Develop a system to monitor repeat prescription box to ensure requesting and collecting repeat prescriptions process works effectively.
• Maintain records when the prescribing competence of a non-medical prescriber is reviewed and discussed with them.
• Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake rates.
• Take necessary steps to address CQC registration issues.

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 Hospitals and Interim Chief Inspector of Primary Medical Services