We carried out an announced comprehensive inspection at Church Road Surgery on 17 November 2022. Overall, the practice is rated as good.
Safe - good
Effective - good
Caring - good
Responsive - good
Well-led - outstanding
Why we carried out this inspection
This inspection was a comprehensive inspection due to changes to the registration of the provider and includes the safe, effective, caring, responsive and well-led key questions.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- 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 Good overall and outstanding in Well-led.
We found that:
- 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.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- There was a good working relationship with the Patient Participation Group (PPG), which supported the practice with patient interaction and improving service delivery.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Staff at all levels were encouraged to speak up and raise concerns.
- There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way which meets those needs, which was accessible and promoted equality.
- Services were developed with the full participation of those who use them, staff and external partners.
- Staff who worked at the practice were consistently positive about teamwork; being involved in decision making; and being supported to carry out their roles.
The practice is rated as outstanding in well-led because:
- The practice provided high quality care and treatment to patients which was driven by effective governance and leaders inspired staff to provide patients with the highest quality evidence-based primary care.
- There was a strong emphasis on learning, evaluation and impact and a willingness to try new ideas to benefit patients.
- The practice was innovative and used technology to demonstrably act on its vision by carrying out a number of quality improvement projects to meet the changing demands of the population.
- The provider participated in research projects and used internal audit and quality improvement programs to review and improve care and treatment. There was a focus on sharing the work of the practice locally and nationally as well as a shared commitment at all levels to learn from others.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services