Hightown Village Surgery

We carried out this review at Hightown Village Surgery on 8 June 2021 to follow up on a requirement notice served following the comprehensive inspection of 19 November 2019.

Following our previous inspection on 19 November 2019, the practice was rated ‘Good’ overall and but ‘Requires improvement’ for providing safe services. Following this review the practice is now rated as ‘Good’ for providing safe services.

The other key questions remain unchanged as does the overall rating.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

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

Why we carried out this review

This review was to follow-up on a requirement notice that we had served as a result of a breach in regulation. We did not undertake a site visit as part of this review. The review focused on areas of the safe key question and actions that had been taken to meet the breach in regulation. We also looked at how the provider had made additional improvements in line with recommendations we had made.

We reviewed the breaches of Regulation 15 HSCA (RA) Regulations 2014 (Premises and equipment) identified at the last inspection. The regulation had not been met because: The provider had not carried out a comprehensive health and safety risk assessment and identified required actions to mitigate identified risks. We had noted risks associated with; access for people who are disabled, maintenance of the building, safety of the staircases, infection control arrangements and pest control arrangements.

We also reviewed an area where the previous inspection identified that the provider should make an improvement by asking the provider to tell us what they had done to demonstrate the management of patient safety alerts.

How we carried out the review

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 reviews differently.

This included:

• Speaking with the practice manager.
• Requesting evidence from the provider.
• Reviewing action plans sent to us by 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 reviewed the information submitted by the provider.
• information from our ongoing monitoring of data about the service.
• Information from local stakeholders.

We have rated this practice as Good for providing safe services and overall.

We found that:

The provider had taken action to improve the safety of the premises and plans were in place to improve the accessibility of the premises. The actions taken included:

• A risk assessment had been carried out in relation to health and safety of the environment.
• Action had been taken to address or mitigate identified risks.
• Access for people who are disabled had been reviewed and plans were in place to improve this.
• Action had been taken to reduce or mitigate the risk associated with the staircases.
• Infection control arrangements had been reviewed and improvements planned.
• Pest control arrangements had been reviewed.

We also found the following improvement had been made in response to our recommendations:

• The system in place for managing safety alerts had been improved to demonstrate that action had been taken in response to alerts.

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

• Continue to work with other agencies to improve the premises and manage risks associated with this and to ensure the planned work/improvements are completed.

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.