We carried out an announced inspection at Dr Jefferies and Partners from 6-8 September 2021. Overall, the practice is rated as good.
Safe - Good
Effective - Good
Well-led - Good
Following our previous inspection on 24 January 2019, the practice was rated good overall and for all key questions and population groups.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Jefferies and Partners on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection to follow up:
- Information of concern received by CQC about the safety of the service
- The inspection focused on the key questions for: safe, effective and well-led. The ratings for the key questions: caring and responsive will be carried forward from the previous inspection.
We also followed up on some specific issues identified for improvement from the previous inspection. These were:
- low uptake of childhood immunisations and cervical screening
- the lack of a proactive approach to monitoring and reviewing vulnerable patients
- the need to strengthen links with health visitors in relation to safeguarding
- the high rate of Quality and Outcomes Framework (QOF) personalised care adjustments (exception reporting)
- the need to develop quality improvement activity
- the need to identify and support patients who are carers.
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
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 for all population groups.
We found that:
- Prior to the inspection, CQC received concerning information about specific aspects of safety at the practice. The inspection showed that these concerns were unfounded.
- The practice had effective systems in place to manage most risks.
- 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.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
- The practice had addressed or was in the process of addressing the areas identified at the previous inspection for improvement.
While we found no breaches, the provider should:
- Ensure that clinical records clearly reflect the clinical rationale in cases where prescribing falls outside of practice policy or national guidelines.
- Continue work to improve the uptake of childhood immunisations and cervical screening.
- Review the demand and supply of practice nursing appointments.
- Continue work to ensure comprehensive clinical coding of diabetes.
- Record the immune status of staff in line with national guidelines.
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