Highwoods Surgery

We carried out an announced inspection at Highwoods Surgery on 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 – requires improvement

We had inspected the practice under the previous provider’s registration on 24 May 2016 and the practice was rated as good overall. 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 Highwoods Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This was a comprehensive inspection of the practice under the new provider’s 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 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.
• The practice had effective systems to ensure all emergency medicines and equipment was safe to use.
• 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. Patient feedback was positive, and GP survey results were in line with local and national results.
• 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 quality, person-centre care. We were told about recent improvements to the service, but these actions needed to be fully embedded to demonstrate their effectiveness.
• Further review and improvement to their policies and some processes was needed.

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

• Continue to further embed auditing and quality improvement programme work.
• Continue the recently established monitoring of psychotropics medicines to ensure appropriate levels of prescribing.
• Continue with the updated monitoring process to ensure all reviews and pathology recordings are completed effectively.
• Continue to improve immunisation uptake.
• Continue to improve cervical screening uptake.

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