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Graham Road Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 5 November 2021

We carried out an announced inspection at Graham Road Surgery on 19 August 2021, the practice is rated requires improvement.

Safe - requires improvement

Effective - inadequate

Caring - requires improvement

Responsive - requires improvement

Well-led - requires improvement

Why we carried out this inspection

We undertook this inspection in response to intelligence to suggest there was emerging risk at this practice. As this inspection was the first inspection since Graham Road was registered with this new provider we completed a comprehensive inspection in order to provide this location with a rating.

How we carried out the inspection

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 inspections differently. This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing

• 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

• A short site visit

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 Requires improvement for population groups. For people with long-term conditions and Families, children and young people we rated this practice as Inadequate. We rated the practice as Requires improvement for Working age people, People experiencing poor mental health, Older people and People whose circumstances make them vulnerable.

We found that:

  • The practice adjusted how it delivered services to meet the needs of patients during the Covid-19 pandemic, however patients had issues accessing care and treatment in timely way.
  • The practice were carrying staff vacancies which was impacting on safe and effective care and treatment to patients. However, there was a plan in place to actively recruit to roles
  • The practice had a fire procedure in place and staff were trained in fire safety, however the practice was unaware that a fire risk assessment completed by a landlord was out of date and had not completed their own risk assessment.
  • The practice followed national guidance to assess patients remotely during the Covid-19 pandemic, however not all patients with long-term conditions had regular health checks done and there was a backlog of summarising patients notes.
  • The practice was not effective in monitoring Quality of Framework (QOF) data and fell below national averages for number of conditions.
  • Performance for national prevention schemes for example child immunisation was below 90% minimum uptake.
  • Not all staff felt supported and not all of them had received regular supervision or appraisal.
  • The leadership team were in the process of identifying ways to make improvements to delivery but these changes were either in the pipeline or in their infancy and so were unable to assess whether these would result in sustainable change and improvement.
  • The leadership team were working with other organisations to seek improvements for their patients.

We found two breaches of regulations:

  • Regulation 12 HSCA (RA) Regulations 2014 Safe care and Treatment
  • Regulation 17 HSCA (RA) Regulations 2014 Good governance

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

Inspection areas


Requires improvement




Requires improvement


Requires improvement


Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people


Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement