We carried out an announced review of Shepherds Spring Medical Centre on 18 May 2021. Overall, the practice is rated as Good.
Following our previous focussed inspection on 14 November 2019, the practice was rated Good overall but Requires Improvement for providing Well led services.
At this inspection we looked at the following key question:
• Are the services provided at this location well-led?
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shepherds Spring Medical Centre on our website at www.cqc.org.uk
Why we carried out this review
During the previous inspection in November 2019 we found that:
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care but some staff told us they did not feel supported to fulfil the role they had been employed to do.
- The practice had not ensured all policies were well-circulated or known by all staff.
- Staff told us that protected time for learning and development was not always given to allow for the completion of expected training.
At this follow up review we found that improvements had been made and the provider was no longer in breach of the regulations. We have amended the rating for this practice accordingly.
The practice is now rated as Good for the provision of Well Led services.
How we carried out the review
Throughout the COVID 19 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 reviews differently.
This review was carried out in a way which enabled us to spend no 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
- 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 undertook rthis follow up review
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall and Good for all population groups.
We found that:
- There were systems and processes in place to ensure compliance with requirement to demonstrate good governance.
- Staff were clear about their responsibilities relating to significant event reporting procedures.
- The practice was consistent in its approach to sharing information with staff. For example, the plans associated with the completion of staff appraisals, or the awareness of a Whistleblowing policy and the identification of a specific Freedom to Speak Up Guardian.
- Staff felt that if they raised concerns that they would be appropriately addressed.
- Oversight of staff training was appropriate to ensure full compliance with practice’s own training requirements.
- 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.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
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