We carried out an announced comprehensive inspection at Cliffe Woods Surgery on 4, 5 and 6 February 2020. The overall rating for the practice was Good but the Safe domain was rated as Requires Improvement. The full comprehensive report on the February 2020 inspection can be found by selecting the ‘all reports’ link for Cliffe Woods Surgery on our website at www.cqc.org.uk.
After our inspection in February 2020 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.
Why we carried out this inspection:
We carried out an announced focussed follow-up inspection on 27 April 2021 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in February 2020. This report covers findings in relation to those requirements.
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 in line with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
Our judgement of the quality of care at this service is based 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.
This practice remains rated as Good overall.
The key question at this inspection is rated as:
Are services safe? – Good
We rated the practice as good for providing safe services because:
- Risks to patients, staff and visitors continued to be assessed, monitored or managed in an effective manner.
- The provider had made improvements to the arrangements for medicines management to help keep patients safe. However, further review and improvement of some standard operating procedures (SOPs) were required.
The areas where the provider should make improvements are:
- Continue with plans to replace clinical wash-hand basins that do not currently comply with Department of Health guidance at the next refurbishment.
- Continue with plans to deliver the practical element of basic life support training to relevant staff when it becomes available as the pandemic restrictions reduce.
- Consider further review and improvement of SOPs to ensure completeness, correct content and clarity.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care