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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We rated the provider as Inadequate for providing safe services. This was because:
• Safeguarding was not given sufficient priority and staff were not clear who the safeguarding leads were.
• Staff did not undertake mandatory training until six months into their roles. In the absence of training risks
assessments were not undertaken.
• Staff recruitment records were not kept in order to comply with the regulations.
• The arrangements for managing medicines did not always keep patients safe.
• Learning from significant events was not always shared with relevant staff.
• Systems for managing historical safety alerts were not always effective.
• The provider was not effectively assessing and monitoring the clinical capacity to ensure this was sufficient to meet the needs of the patient population. The provider was not acting upon concerns about staffing levels.
We rated the provider as Requires Improvement for providing effective services. This was because:
• Patients’ needs were assessed, but care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
• Patients with long-term conditions were not always receiving relevant reviews that included all elements necessary in line with current best practice guidance. Patient reviews were not always followed up in a timely manner where necessary.
• The practice carried out quality improvement activity, but there was not always evidence that they had implemented and followed up on the recommended changes.
• Cervical cancer screening uptake was well below national averages and continued to steadily decline.
We rated the provider as Good for providing caring services. This was because;
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patient feedback was generally positive about their experiences with the clinical team.
We rated the provider as Inadequate for providing responsive services. This was because:
• Patients were not always able to access care and treatment in a timely way.
• Patients were not able to make appointments in a way that met their needs and patients were highly dissatisfied with telephone access.
• Feedback from patients was not being used to drive improvement.
We rated the provider as Inadequate for providing well-led services. This was because:
• The overall governance arrangements were not fully effective.
• There was a lack of leadership at the practice.
• Arrangements for identifying, recording and managing risks, issues and mitigating actions were not fully effective.
• The provider had not risk assessed the impact of the lack of GPs on site or taken actions to mitigate this.
• Structures, processes and systems for accountability were not clearly set out or understood by staff.
• Patient views were not acted on to improve services.
• Statutory CQC notifications had not been submitted in line with requirements.
We found breaches of regulations. The provider must:
• Ensure care and treatment is provided in a safe way to patients
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Assess, monitor and mitigate the risks relating to the health, safety and welfare of service users.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
• Ensure recruitment procedures are established and operated effectively to ensure that specified information is available regarding each person employed.
The provider should:
• Identify carers to ensure these patients are offered appropriate support.
• Make information on how to make a complaint readily available to patients.
• Ensure procedures for ‘Do not attempt’ (DNACR) are reviewed for all relevant patients.
https://api.cqc.org.uk/public/v1/reports/179b5bdd-5d78-4c0d-8cf0-8c78cd604523?20230309080056