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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https://www.cqc.org.uk/location/1-2710506334
We rated the practice as Inadequate for providing safe services because:
• The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
• Appropriate standards of cleanliness and hygiene were not always met.
• There were gaps in systems to assess, monitor and manage risks to patient safety.
• Staff had some information they needed to deliver safe care and treatment. However, improvements were required.
• The practice had systems for the appropriate and safe use of medicines, including medicines optimisation. However, improvements were needed.
• The practice did not have a robust system to learn and make improvements when things went wrong.
We rated the practice as Requires Improvement for providing effective services because:
• Patients’ needs were not always assessed, and care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
• The practice was unable to demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
• The practice always obtained consent to care and treatment. However, DNACPR decisions were not always made in line with legislation and guidance.
We rated the practice as Requires Improvement for providing responsive services because:
• Complaints were not used to improve the quality of care.
We rated the practice as Inadequate for providing well-led services because:
• There was compassionate and inclusive leadership, however improvements were needed to ensure the delivery of high-quality sustainable care.
• The practice had a culture which drove high quality sustainable care. However, the provider was unable to
demonstrate they had an effective complaints procedure.
• There were some responsibilities and roles to support good governance and management. However, improvements were needed to systems of accountability for the management of backlogs of activity.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• There was little evidence of systems and processes for learning, continuous improvement and innovation.
We found two breaches of regulations. The provider must:
• Ensure care and treatment is provided in a safe way for service users.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should:
• Continue to improve cervical cancer screening uptake.
• Continue to improve child immunisation uptake.
• Use feedback from staff and patients to improve national GP patient survey satisfaction scores.