This practice is rated as Good overall. (Previous rating January 2018 – Good)

We carried out a comprehensive inspection on 5 October 2016 when we found patients were at risk of harm because the practice did not ensure that persons providing care and treatment had the qualifications, competence, skills and experience to do so, staff training was inadequate and staff were acting outside their levels of competency. There were insufficient staff to provide a good level of service to patients and systems and processes were not in place to keep patients safe. There was no systematic approach to assessing and managing risks and practice policies and procedures were not well managed. There was no comprehensive programme of quality improvement and the procedure for reviewing and acting on significant incidents was inadequate. We rated the practice as inadequate overall and the practice was placed into special measures.

We carried out a further comprehensive inspection of the practice on 30 May 2017. We found many improvements had been made and the overall rating for the practice was requires improvement. We took the practice out of special measures.

At our focused re-inspection on 17 January 2018 we found the practice had made further improvements; they were meeting all the required regulations and we rated the practice as good in all the key questions and good overall.

In August 2018, the practice provider changed from an individual GP to a partnership of two GPs.

We carried out an announced comprehensive inspection at Clayton Brook Surgery on 21 February 2019. This inspection was in line with our new methodology to ensure the improvements found at our inspection in January 2018 had been sustained.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

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 good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way; access to the practice had been improved.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care; systems and processes to govern the practice had been strengthened.

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

• Maintain accurate records of all family and household members of vulnerable patients and improve routine communication with health visitors.
• Introduce occupational health checks for new staff members to ensure safe working conditions.
• Review the system for documenting action taken as a result of patient safety alerts.
• Undertake the planned action to improve uptake rates for breast cancer screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice