Caradoc Surgery

We carried out an announced comprehensive inspection at Caradoc Surgery on 23 November 2022. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

When this service registered with us, it inherited the regulatory history from the previous provider. This was the first inspection of the service since Ranworth Surgery registered as the provider of this service with the Care Quality Commission (CQC) in December 2019.

We had inspected the practice under the previous provider’s registration in July 2019 and the practice was rated inadequate overall and for safe, effective responsive and well-led services and requires improvement for caring and put into special measures. Under our continuing regulatory history policy, the rating of inadequate was inherited.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities and it included all of the key questions: safe, effective, caring, responsive and well-led to provide a rating for this practice .

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.
• Staff questionnaires.

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 provider had addressed all the concerns found at the previous inspection. This included improving the previously negative patient survey results, the unsafe poor quality, and ineffective care provided by the previous provider.
• The way the practice was led and managed showed the leadership had oversight to ensure all systems and processes were in place to deliver effective care to all patients.
• The practice had safeguarding processes and procedures that kept patients safe from abuse.
• The practice had effective systems to ensure all emergency medicines and equipment were safe to use.
• There was an effective process used to monitor patients’ health in relation to the use of medicines including high risk medicines, provided appropriate monitoring and clinical review prior to prescribing.
• Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts had been acted on appropriately. However, we did find some actions taken were not documented on patient records.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients we spoke with told us they could access care and treatment in a timely way, were included in their treatment decisions, and felt safe receiving their care and treatment at the practice.
• The practice respected patients’ privacy and dignity, and patient confidentiality was maintained throughout the practice.

Although we found no breach, the provider should:

• Continue to embed the process to monitor and document all actions taken in response to guidance from Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts.
• Continue to encourage uptake for cervical screening and childhood immunisations.
• Continue to embed the process to record and inform patients of their CKD status.
• Increase the identification of carers to improve the health of those people with caring responsibilities.

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