no site visit
During an inspection looking at part of the service
We carried out an announced focused inspection at Cornerstone Family Practice on 9 January 2023. We did not rate the practice at this inspection, as due to winter pressures on the NHS it was completed without undertaking a site visit.
Safe - partially inspected and unrated
Effective - partially inspected and unrated
Caring – not inspected
Responsive – not inspected but commented on access for patients
Well-led - partially inspected and unrated
Following our previous inspection on 13 April 2021 the practice was rated good for the effective key question that had been rated requires improvement from the previous inspection on 8 May 2019; overall the practice remained rated good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Cornerstone Family Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up concerns reported to us.
- We focused on elements of the safe, effective and well-led key questions and asked the provider questions about access to appointments in line with a national initiative.
How we carried out the inspection
This inspection was carried out without visiting the 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.
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 found that systems to ensure safety of patients were in place but not always working effectively and that this had led to gaps in safe service delivery. Other systems such as staff training were not demonstrated as being effective by the practice.
- The practice was lower than target for their uptake of childhood immunisations and cervical screening and leaders were unable to provide data that demonstrated any improvement or evidence that any specific actions had been taken to address these.
- The provider had quality improvement systems in place, but these were generally ineffective.
- Patient satisfaction with access to care and treatment was generally lower than local and national averages.
- The practice demonstrated that although governance arrangements were in place, they were often ineffective and reactionary in nature. We saw several areas where gaps were apparent and practice leaders were not always fully aware or had formal plans to address these.
We found a breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should:
- Link all other relevant records relating to individual safeguarded children in the clinical system.
- Update practice information for clinical staff to reflect national prescribing guidance and implement monitoring arrangements.
- Develop a comprehensive plan to improve cervical screening and childhood immunisation uptake data and monitor.
- Address patient concerns in relation to access to care and treatment.
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