Updated 8 April 2025
Date of Assessment: 7 July 2025 to 22 August 2025. The Caxton Surgery is a GP practice and delivers service to 14,181 patients under a contract held with NHS England. The National General Practice Profiles states that the patient ethnicity profile is made up of 96.91% White, 1.23% Asian, 0.7% Black,0.7% Mixed and 0.46% other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
At the last inspection in November 2022, under our previous methodology, the practice was rated requires improvement overall, requires improvement for providing safe and effective services and rated good for providing caring, responsive and well led services.
This announced focused assessment was carried out to follow-up on the breach identified at our last inspection. Since the last inspection, the practice had made improvements and is no longer in breach in relation to safe care and treatment. However, during this assessment we identified a legal breach relating to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.
SAFE:
The service had a learning culture and people could raise concerns. Managers investigated incidents and complaints however, the management of complaints was inconsistent and not in line with the practice policy. Staff understood risks but risks associated with health and safety of the premises were not always managed effectively. The facilities were clean. There were enough staff with the right skills, qualifications and experience, however, not all staff had been recruited safely. Managers made sure most staff had received training and regular appraisals to maintain high-quality care. Some shortfalls were identified in how staff managed medicines.
EFFECTIVE:
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services.
Staff made sure most people understood their care and treatment. When a person lacked capacity, staff involved those important to the person and took a multi-disciplinary approach when making decisions in the person’s best interests. However, they did not always ensure an assessment of mental capacity had been recorded.