25 August 2021 and 26 August 2021
During a routine inspection
Following our previous inspection on 12 July 2019. The practice was rated Requires Improvement overall and for the effective and well-led key questions. The caring key questions was rated good. The ratings for the safe and responsive key questions was good and was amalgamated from the previous inspection.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Glyndon PMS on our website at www.cqc.org.uk.
This inspection was an announced comprehensive inspection carried out on 25 August 2021 and 26 August 2021. Overall, the practice is rated as Requires improvement. The inspection looked at the following key questions:
Safe - Good
Effective – Requires Improvement
Caring - Good
Responsive - Good
Well-led – Good
The population groups, people with long-term conditions, families, children and young people and working age people were rated Requires 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.
Part of the inspection was carried out remotely with the intention of us spending 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:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on 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.
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:
- The practice’s Quality and Outcomes Framework (QOF) showed an improvement in several indicators compared to the data from 2017/18; however, there were areas where practice performance was still below the local and national average.
- Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates for the vaccines given were below the target of 90% in four areas where childhood immunisations are measured.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- We found instances when the provider had not carried out appropriate monitoring of patients on high risk drugs.
- The practice had identified 1% of patients as carers.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- 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 timely way.
We found breaches of regulations. The provider must:
- Ensure that care and treatment is provided in a safe way.
There were areas where the provider should:
- Continue to implement a programme to improve uptake for cervical screening and explore the reason why childhood immunisations uptake is higher for children aged one, compared to other age groups.
- Review the threshold for safety incident reporting to ensure potential misses are captured and learning opportunities identified.
- Ensure all staff are up-to-date with their booster vaccinations, in line with Public Health England guidance.
- Take action to review patients listed on the practice’s safeguarding list.
- Consider introducing a hearing loop, information in different languages and in an easy read format in the practice’s reception area.
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