Abbey Road Surgery

We carried out an announced inspection at Abbey Road Surgery on 4 May 2022. Overall, the practice is rated as Good.

The key question ratings are as follows:

Safe - Good

Effective – Good

Caring – Good

Responsive – Good

Well-led – Good

This is the first time this practice has been inspected under its current CQC registration.

Why we carried out this inspection

This inspection was a comprehensive inspection to check the provider was complying with the regulations under the Health and Social Care Act 2008. We inspected all five key questions to determine if the service is safe, effective, caring, responsive and well led.

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 remotely using video conferencing;

• Speaking with the PPG chair remotely via the telephone;

• 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 for remote analysis;

• A shorter site visit;

• Further communications for clarification.

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;

• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• The way the practice was led and managed promoted the delivery of person-centre care and protected patients from avoidable harm;
• Patients received effective care and treatment that met their needs although the monitoring of high-risk medicines was in need of review for some patients;
• The practice had identified areas for improvement and had developed action plans to ensure continuous improvement;
• Staff dealt with patients with kindness and respect and utilised social prescribing to help improve patient’s health and wellbeing;
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic;
• Patients could access care and treatment in a timely way.

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

• Ensure the management of patients prescribed high-risk drugs is being completed in accordance with recommended best practice guidelines;
• Include the contact details of the parliamentary and health service ombudsman in complaint correspondence and review the process for recording lessons learned;
• Continue with plans to develop and expand the work of the patient participation group.
• Support staff to complete refresher and outstanding training as identified on practice training records.

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