- GP practice
Mayfield Surgery
All Inspections
14 & 15 June 2022
During a routine inspection
We carried out an announced inspection at Mayfield Surgery on 14 and 15 June 2022. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Why we carried out this inspection
This inspection was a comprehensive inspection as the practice had not been inspected since registering with the CQC in October 2019.
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
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- There was evidence of effective systems and processes to support safe medicines management.
- Patients received effective care and treatment that met their needs.
- Clinical staff received regular updates and training and took steps to ensure they were familiar with the most recent clinical guidelines.
- There was a programme of quality improvement, including clinical audit.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the National COVID-19 pandemic. Patients could access care and treatment in a timely way.
- There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
- The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- The practice team demonstrated a commitment to learning and improvement at all levels of the organisation.
Whilst we found no breaches of regulations, the provider should:
- Continue to follow up on patients with a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decision in place, to ensure records are accessible to all involved in the patients care.
- Continue with efforts to encourage patient uptake of the cervical cancer screening programme.
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