The intention of sharing the content of this report is to assist practices that have not yet been inspected. They can use the summarised version of the report to identify risk areas in their own practice, creating a suitable action plan to reduce the associated risk prior to inspection.
We understand how painful and damaging a CQC inadequate report is to practice and its team. If you have been personally affected by this report please get in touch. We will offer a listening ear.
If you need more formal support we would recommend the “Looking after you team”. They offer an non-judgmental coaching support service: https://www.england.nhs.uk/supporting-our-nhs-people/support-now/looking-after-you-confidential-coaching-and-support-for-the-primary-care-workforce/looking-after-you-too/
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Review December 2022:
• The system to manage complaints information had improved since the last inspection.
• The system to manage significant events had improved since the last inspection.
• The practice had a comprehensive programme of quality and improvement activity.
• The practice had addressed some of the concerns in relation to the premises and equipment. However, further improvements were still required. For example, in relation to legionella and management of vaccines.
• The practice was able to show that staff had the skills, knowledge and experience to carry out their roles.
• There remained gaps in systems to assess, monitor and manage risks to patient safety. For example, in relation to legionella and infection control.
• Leaders could demonstrate that they had the capacity and skills to deliver high quality sustainable care.
• The overall governance arrangements had improved.
We found a continued breach of regulations. The provider must:
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Review October 2022:
We found that:
- The practice did not provide care in a way that kept patients safe and protected them from avoidable harm.
- Patients did not receive effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could not access care and treatment in a timely way.
- The way the practice was led and managed did not promote the delivery of high-quality, person-centred care.
- Leaders could not demonstrate they had the capacity and skills to deliver high quality sustainable care.
- The overall governance arrangements were inadequate.
- Staff did not always work effectively together and with other organisations to deliver effective care and treatment.
- The practice did not have a comprehensive programme of quality improvement activity.
- Patients’ needs were not assessed, and care and treatment was not delivered in line with current legislation.
- There were gaps in systems to assess, monitor and manage risks to patient safety.
We found four breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
- Ensure all premises and equipment used by the service provider is fit for use.
- Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
- Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints be patients and other persons in relation to the carrying on of the regulated activity.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should:
- Take steps to improve safe levels of staffing.
- In response to patient feedback, improve access for patients.
- Take action to improve staff wellbeing.