Archived: The Village Surgery

We carried out an announced follow up inspection at The Village Surgery on 5 and 6 October 2021 as the practice had previously been rated Requires Improvement. At the last inspection we identified the following areas for improvement:

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Act to complete the actions highlighted in the fire risk assessment of 6 February 2020.
• Act to ensure the building plans for the new practice premises are completed as scheduled so the space constraints of the current location are resolved in a timely way.
• Act to achieve the 95% WHO based target for childhood immunisations.
• Act to achieve the cervical cancer screening 80% national programme coverage measure set by Public Health England.

We found the provider had made improvements at this inspection in all of the areas above. The provider had moved to a new purpose built premises in August 2021. Whilst the practice was just under the target for cervical screening and one of the childhood immunisation targets, they had worked hard to improve uptake and were continuing to do so.

We were mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what type of inspection was necessary and proportionate. This is why there was a delay in reinspecting this service.

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.

Key findings included:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice now had a comprehensive system in place to learn from significant events and complaints.
• The practice had completed two cycle audits over the last 12 months to improve outcomes for patients including a two week wait audit.
• Most patients we reviewed had received annual reviews in a timely manner. There were a couple of patients who hadn’t received their review in the recommended timescale due to the pandemic. The practice rectified this straight after the inspection and called them in for their blood tests straightaway.

The provider should:

• Continue to improve its cervical screening uptake rates.
• Continue to improve its childhood immunisations uptake rates.
• Review the electronic patient system to ensure that all patients are coded correctly.
• Continue to have timely reviews for patients with long-term conditions.

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