15/10/2019
During an inspection looking at part of the service
We carried out a focused inspection at Dr Ugo Umeadi (also known as Cleggs Lane Medical Practice). The announced inspection was following our annual regulatory review with the practice which had identified changes in the practice which triggered this inspection. We inspected the domain areas of effective and well led and utilised information from our previous inspection findings for the domain areas of safe, caring and responsive. 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:
- 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.
- The way the practice was led and managed promoted the delivery of person-centre care.
We rated the practice as good for providing effective services because:
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
- The practice understood the needs of its population and tailored services in response to those needs.
We rated the practice as good for providing a well led service because:
- There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of person-centre care.
- The practice proactively sought feedback from staff and patients, which it acted on.
The areas where the provider should make improvements are:
- The practice should have a structured audit plan in place.
- The practice should continue to improve on their childhood vaccination 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