21 May 2021
During an inspection looking at part of the service
We carried out an announced inspection at St Chads Medical Practice on 21 May 2021.
Overall, the practice is rated as good.
We previously inspected the practice on 15 March 2019. At that inspection the practice was rated requires improvement overall, with the following key question ratings:
Safe – requires improvement
Effective – requires improvement
Caring – good
Responsive – good
Well-led – requires improvement.
We issued requirement notices in respect of breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014.
At this inspection on 21 May 2021 we inspected the key questions safe, effective and well-led. We rated all these key questions good. The previous ratings of good for the key questions caring and responsive remain in place.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for St Chads Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection of the key questions safe, effective and well-led. It was carried out to check that the required improvements following the March 2019 inspection had taken place, and to allow a new rating to be awarded. This inspection had been delayed due to the Covid-19 pandemic.
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:
- 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
- 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 have rated this practice as good overall and good for all population groups.
We rated the practice good for providing safe services because:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. Improvements had been made as follows:
- A system was in place to check the ongoing professional registration of clinicians.
- A health and safety risk assessment had been carried out.
- There was a system to check and record the safety of the oxygen and defibrillator.
- There was a risk assessment in place relating to emergency medicines to ensure all relevant medicines were held by the practice.
- A system was in place to check patients had attended urgent appointments.
- Significant events were reviewed.
We rated the practice good for providing effective services because:
- Patients received effective care and treatment that met their needs. Improvements had been as follows:
- All test results had been actioned and there was a system in place to ensure test results were actioned in a timely manner.
- There was a programme of clinical audits, and this was followed and completed.
- There was a system to record and monitor all staff training. Staff training was up to date at the time of inspection.
- The latest available QOF data was for 2019-20. This indicated some below average performance. Performance for some indicators had been affected by the Covid-19 pandemic, and in some areas, for example, cervical screening, the practice was able to provide us with more recent unverified data.
The rating of good for the key question caring remained in place from the 15 March 2019 inspection.
The rating of good for the key question responsive remained in place from the 15 March 2019 inspection.
We rated the practice good for providing well-led services because:
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Improvements had been as follows:
- There was evidence of risk assessments for all aspects of the practice.
- Policies were in place that related to the practice and these were regularly reviewed.
- We saw systems in place to ensure learning and continuous learning.
- There was a programme of clinical audit.
- There was formal support and assessment in place for all staff.
The areas where the provider should make improvements are:
- Ensure records of hospital blood test results are retained so they are available for all staff, including locum clinicians, who may need access to them.
- Make sure policies are fully personalised for the practice. For example, there were some gaps in the safeguarding policy.
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