13 December 2022
During a routine inspection
We carried out an announced comprehensive inspection at Dr Jude's Practice - Riverside & Picton on 8 and 13 December 2022. Overall, the practice is rated as requires improvement. The ratings for each key question are:
Safe - good
Effective - requires improvement
Caring - requires improvement
Responsive - requires improvement
Well-led - good
Following our previous inspection on 9 March 2022, the practice was rated requires improvement overall and for all key questions the practice was rated:
Safe - requires improvement
Effective - requires improvement
Caring - requires improvement
Responsive - requires improvement
Well-led - inadequate
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Jude's Practice - Riverside & Picton on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A site visit.
Our findings
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 found that:
We have rated this practice as requires improvement overall.
We rated the practice as good for providing safe services. This is because:
- At this inspection, we found that those areas previously regarded as requiring improvement had been addressed and appropriate actions taken by the provider. The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
We rated the practice as requires improvement for providing effective services. This is because:
- The practice achievement in cervical cancer screening and childhood immunisations continued to be below nationally set targets.
We rated the practice as requires improvement for providing caring services services. This is because:
- The provider had taken action to monitor patient views by monitoring the results of the GP national survey and actions plans were in place. However, the provider had not undertaken a practice patient survey and feedback from patients in the national GP patient survey were below local and national averages relating for questions about care and concern from staff.
We rated the practice as requires improvement for providing responsive services because:
- Complaint records did not provide sufficient detail to demonstrate that all complaints were investigated thoroughly and without delay. The provider did not maintain a record of all complaints, outcomes and actions taken in response to complaints made to the practice.
We rated the practice as good for providing well led services because:
- At this inspection, we found that those areas previously regarded as inadequate had been addressed and appropriate actions taken by the provider. Leaders demonstrated they understood the challenges to quality and sustainability. The practice had a culture which drove high quality sustainable care. There were clearer and improved processes for managing risks, issues and performance.
We found one breach of regulations. The provider must:
- Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or its investigation.
The provider should:
- Take action to ensure all staff who may be exposed to blood, body fluids or tissues as part of their work activity should have pre-exposure immunisation against HBV.
- Involve patients and the public in infection prevention and control by providing alcohol hand rub at the entrance to the building for the use of patients and visitors.
- Undertake a risk assessment for the use of a shared automated external defibrillator (AED). Checks of emergency medicines should be carried out weekly.
- Continue to monitor and provide evidence of effective medicines reviews for patients on repeat medicines.
- Improve staff administration of prescription only medicines under a patient group directive to include appropriate authorisation.
- Continue to take steps to improve the childhood immunisations and cervical screening rates for the practice.
- GPs and practice staff should ensure that records relating to DNACPR decisions are available on patients record systems, particularly as they move between patient services such as hospital and primary care.
- Continue to take steps to improve the results of the national GP patient survey.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services