We carried out an announced inspection at Dr Cyril Stephen, also known as Boyatt Wood Surgery and visited the practice on 19 May 2021.
Overall, the practice is rated as Good.
The ratings for each key question are as follows:
Safe - Good
Effective - Good
Caring - Good (carried over from the previous inspection)
Responsive - Good (carried over from the previous inspection)
Well-led - Good
Following our previous inspection, published on 1 May 2019, the practice was rated Requires Improvement overall, with requires improvement ratings given for the two key questions Safe and Effective. We issued a requirement notice against Regulation 12 of the Health and Social Care Act Regulations 2014, Safe care and treatment. We judged there to be inconsistent safe management of medicines. The key questions of Caring, Responsive and Well Led were rated Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Cyril Stephen on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a follow-up inspection, to follow up on the areas identified for improvement in the last inspection, including a breach of regulations and ‘shoulds’ identified in the last inspection. We inspected the three key questions, Safe, Effective and Well Led as part of our new methodology for inspecting services with a requires improvement rating.
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 short site visit
- Requesting feedback from the patient participation group (PPG).
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 Good for all population groups.
We found that:
- The practice had made changes and improvements in the areas we identified as requiring improvement at our last inspection. These included improvements in the care of the different population groups and the management of medicines
- 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 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-centred care.
Whilst we found no breaches of regulations, the provider should:
- Continue to review and optimise prescribing levels for antibiotics, including the duration of the prescription.
- Document patient discussions in relation to risk factors associated with different medicines.
- Continue to log the actions taken in response to safety alerts and include the details of specific actions taken and by whom.
- Develop a more streamlined approach for creating and managing information internally, to support communication and the practice’s development within the wider PCN.
- Relaunch a quality improvement programme, disrupted by the practice’s COVID-19 response.
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