29 September 2021
During an inspection looking at part of the service
We carried out an announced inspection at Upton Road Surgery (also known as Watford Health Centre) on 29 September 2021. Overall, the practice is rated as Good.
Safe - Good
Effective – Requires Improvement
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection published in October 2019, we rated Upton Road Surgery as Requires Improvement overall. We rated the practice as Requires Improvement for providing Effective, Responsive and Well-led services; and as Good for providing Safe and Caring services.
The full report for the previous inspection can be found by selecting the ‘all reports’ link for Upton Road Surgery on our website at www.cqc.org.uk.
Why we carried out this inspection
This inspection was a comprehensive, follow-up inspection, to review breaches of regulations identified at our previous inspection, and to ensure required actions had been taken.
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 and telephone calls.
- 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, data and information from the provider.
- Carrying out desktop reviews of documentary evidence, including policies and procedures.
- Reviewing information from stakeholders.
- 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.
- information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall and Good for Older people; People with long-term conditions; People whose circumstances may make them vulnerable; and People experiencing poor mental health (including people with dementia).
We have rated this practice as Requires Improvement for Families, children and young people and Working age people (including those recently retired and students).
We found that:
- The practice had made and sustained some of the improvements required to address the concerns identified at our last inspection. Systems had been implemented to monitor clinical and quality monitoring.
- Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets.
- The practice’s cervical cancer screening rate was below the national target.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- The practice had clear and effective systems to ensure patients on medicines received regular monitoring in a timely way.
- 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.
- 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 take action to further increase the uptake of childhood immunisations.
- Continue to take action to further increase the uptake of cervical screening.
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