Maple Surgery

We carried out an announced inspection at Maple Surgery on 15 June 2022 Overall, the practice is rated as good.

The ratings for each key question are:

Safe - Good

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led – Good

When this service registered with us, it inherited the regulatory history and ratings of its predecessor. This is the first inspection of Maple Surgery under the registered provider MKGP Plus Limited who became the provider from April 2020.

We had inspected the practice under the previous provider’s registration in January 2019 and the practice was rated as good overall and requires improvement for the responsive key question. Under our continuing regulatory history policy, the rating of good was inherited.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Maple Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to rate the practice under the new registration.

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
• Staff questionnaires

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.
• The system for ensuring all emergency medicines and equipment were safe to use required strengthening.
• We found no system in place for assurance relating to external cleaning staff having a Disclosure and Barring Service (DBS) check or a risk assessment.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice respected patients privacy and dignity and patient confidentiality was maintained throughout the practice.
• GP patient survey data was below CCG and national averages, and the practice had not fully engaged in patient feedback exercises to understand patients poor experiences of accessing the practice.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Review and improve the opportunities for patients to access health checks.
• Continue to encourage patients to attended for childhood immunisations and encourage patients to attend for the national cervical screening programme to increase uptake.
• Engage in patient feedback exercises to further improve and measure improvements to services.
• Review and improve systems to ensure all emergency medicines and equipment were safe to use.
• Improve systems and processes for assurance of external staff.

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