The Drive Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that the service routinely monitored people's care and treatment and took action to improve outcomes.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating remains Requires Improvement. We, however, acknowledge the significant improvements made to childhood immunisation uptake and cervical screening coverage in monitoring and improving outcomes.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. Since the previous assessment, the service had improved outcomes in several key areas. Cervical screening rates had increased significantly. At the previous assessment, the combined screening rate was below the 70% minimum acceptable level. Women aged 50 to 64 were now screened at a rate of 86 in every 100, above the national target of 80 in every 100. Women aged 25 to 49 were screened at a rate of 76 in every 100, an improvement from approximately 57 in every 100 at the time of the previous assessment and above local and national averages, though below the national target of 80 in every 100. For childhood immunisations, the first dose of MMR vaccination at age two had improved from 76 in every 100 children to over 90 in every 100, above the England average of 88 in every 100. The primary vaccination course at age one had improved from 80 in every 100 children to just under 90 in every 100, and the pneumococcal booster at age two had improved from 78 in every 100 to 86 in every 100, moving out of the lowest CQC performance band. “The service had clear operational systems in place to support these improvements, including completing a formal audit cycle that reduced missed vaccination appointments from around 8 in every 100 to 3 in every 100, weekly recall activity supported by a dedicated care coordinator, documented use of a structured clinical template for vaccination decisions, and the recruitment of a bilingual nurse to help reach patients facing language or cultural barriers. Staff individually reviewed national child health data each month to identify children with incomplete vaccinations and arranged support, such as interpreter services where needed. The service had also been working with NHS England on plans to offer HPV self-sampling to women who had not responded to screening invitations, with this expected to be available by summer 2026. The practice had become a GP training practice since the previous inspection, reflecting improvements made to its governance and clinical standards. Operational staff demonstrated awareness of recall processes and their individual responsibilities, which was reflected in both their responses to the assessment and in records reviewed. However, whilst improvements had been made, no childhood immunisation indicator had reached the WHO-recommended target of 95%, and the majority remained below the 90% national minimum standard. These shortfalls had been identified across multiple consecutive assessments, and the service had not yet demonstrated the consistent and positive outcomes required for a Good rating. Uptake for pre-school booster vaccinations, including the second MMR dose, was a particular concern, having declined since the previous assessment and remaining in the lowest performance category against national standards. At the time of the assessment, a specific improvement plan for this cohort had not been documented, and the service's standard operating procedures did not include version numbers, review dates or a document history to confirm that monitoring processes were established and subject to regular review. Cervical screening for women aged 25 to 49 also remained below the national target. The service had identified these areas as priorities and was continuing to work towards further improvement.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.