We carried out an announced inspection at Ashwell Medical Centre on 23 and 28 September 2021. Overall, the practice is rated as Good.
The ratings for each key question are:
Safe - good
Effective – good
Caring - good
Responsive - good
Well-led – good.
The practice was inspected on 13 February 2019 and was rated as requires improvement overall and requires improvement for providing caring and responsive services. All of the population groups were rated as requires improvement.
A comprehensive follow-up inspection was completed on 10 March 2020. Following this inspection, the practice was rated as requires improvement overall and requires improvement for providing safe, effective and well-led services. The population groups; families, children and young people and working age, were also rated as requires improvement. We rated caring and responsive as good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ashwell Medical Centre on our website at www.cqc.org.uk
At this inspection we rated the practice as good overall and good in all five key questions. We rated all the population groups as good.
Why we carried out this inspection
This inspection was a comprehensive follow-up inspection to check that improvements had been made in respect of concerns and issues identified at our previous inspection.
At the last inspection in March 2020, breaches of regulation 12, safe care and treatment and regulation 17, good governance of the Health and Social Care Act 2008 (regulated activities) Regulations 2014 were found and it was noted that the practice should make the following improvements:
- Continue to encourage and improve uptake rates for childhood immunisations.
- Continue to encourage and improve uptake rates for cancer screening programmes, particularly those relating to cervical screening.
- Develop systems to monitor and track referrals.
- Improve systems for reviewing complaints and concerns to ensure learning arising from these is captured and embedded into processes for continuous improvement.
How we carried out the inspection.
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Completing clinical searches of the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A site visit
- Requesting staff complete feedback forms.
During the site visit we conducted interviews with the registered manager and lead GP, the business manager, the assistant manager, the lead nurse, patient engagement lead, the referrals lead and the data quality manager.
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.
At this inspection we found:
- At this inspection we found that the provider had responded to the previous concerns and breaches of legislation. We saw that improved systems and processes supported good governance.
- During the inspection we found that the actions which the practice were taking to encourage the uptake of immunisations and cancer screening supported good care. We found that improvements had been made in the uptake rates for childhood immunisations, bowel and breast screening.
- The provider had developed a system to monitor and track referrals. We saw that patients were supported through the process of choosing and making an appointment in secondary care.
- The support offered by the team to a local nursing home was described by the home manager as exceptionally positive. We were told that nothing was too much trouble for the team, weekly reviews were carried out and visits made on request throughout the COVID-19 pandemic.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a variety of ways at a time to suit them.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- We saw that the practice was managing complaints as per their policy and these were used to drive improvement.
We saw an area of outstanding practice :
- End of life care was person-centred, family orientated and delivered in a culturally sensitive and coordinated manner. When a terminal diagnosis was received, the GP, patient engagement lead and a community team member visited the patient at home. This appointment aimed to identify a named family contact to ease communication with the practice and begin difficult conversations regarding the person’s wishes. For example, this included offering advice regarding benefits and available support, do not resuscitate orders and a preferred place of death discussion. The family were also offered a copy of the newly implemented practice protocol for managing bereavement and continued support.
Whilst we found no breaches of regulations, the provider should:
- Review historical safety alerts to reduce the potential for error with patients who take a combination of medicines which may interact with each other.
- Take steps to improve the recording of meeting minutes, to provide enough information to update those staff who were unable to attend the meeting.
- Continue to encourage and improve uptake rates for childhood immunisations.
- Continue to encourage and improve uptake rates for cancer screening programmes, particularly those relating to cervical screening.
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