Castle Meadows Surgery

We carried out an announced inspection at Castle Meadows Surgery on 22 November 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Why we carried out this inspection

This inspection was a comprehensive inspection and was carried out as part of our inspection programme. The inspection included:

• The safe, effective, caring, responsive and well-led key questions.

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 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 Good overall

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
• Patients received effective care and treatment that met their needs.
• Staff had the skills, knowledge and experience to deliver effective care, support and treatment. There was clinical oversight and effective systems for quality improvement.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• 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.
• There were processes in place to manage risk, issues and performance.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

• Continue to improve systems to identify carers registered at the practice so they can be better supported.
• Improve the system to manage complaints including the documentation when responding to written complaints.

We found an area of outstanding practice:

• Through the pandemic the practice was flexible in providing telephone and face to face appointments to meet the needs of their population. Evidence we reviewed showed from April 2021 to November 2021 the practice offered a significant amount of additional appointments each week compared with contractual arrangements. We saw evidence of the practice responding to meet the needs of vulnerable patients even when the practice had met capacity.

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