26 September 2023
During an inspection looking at part of the service
We carried out an announced focused inspection at Dr Barber and Partners on 26 September 2023. Overall, the practice is rated as Good.
Safe –Good.
Effective – Good.
Caring – Good.
Responsive – Good.
Well-led – Good.
Following our previous inspection on 6 December 2022, the practice was rated Good overall and Good for providing Safe, Effective, Caring and Responsive services. The practice was rates as Requires Improvement for providing Well-Led services.
From the inspection on 6 December 2022, the practice was told they must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Barber and Partners on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused follow-up inspection to follow up on the Requires Improvement rating for Well-Led at the last inspection in December 2022. The practice was found to be in breach of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014. A requirement notice was issued.
In December 2022, we rated the practice as Requires Improvement for providing Well-Led services because:
- We found governance systems relating to oversight of staff training needed strengthening.
In addition, we told the provider they should:
- Continue to review staff recruitment systems, particularly those relating to disclosure and Barring Checks (DBS) for non-clinical staff to ensure risks remain minimised.
- Continue to encourage and engage patients to attend for cervical screening.
- Undertake repeat cycle clinical audits to monitor improvements made.
How we carried out the inspection
This inspection was carried out in a way which enabled us to avoid an on-site visit.
This included:
- Requesting evidence from the provider.
- Reviewing evidence sent in advance of the inspection to demonstrate action taken and improvements made.
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:
- Improvements had been made to management systems to support staff training, reducing risks to patients and staff. Evidence provided demonstrated records of training were well maintained.
- The practice evidenced that DBS checks were undertaken for all staff.
- The practice provided assurance that efforts were being made to improve patient uptake of cervical cancer screening services. For example, patient feedback highlighted that the majority of eligible patients preferred to attend at weekends or outside of normal working hours. In response, the practice was working with the local extended access hub and nurses were providing a Saturday cervical smear clinic. The practice advised this, amongst other initiatives, such as increased advertising on social media and improved information for patients, had resulted in improved uptake. The practice advised an audit of uptake for this service was scheduled for December 2023.
- Evidence provided demonstrated improvements in the use of regular audits to monitor patient safety, quality improvement work and practice systems. For example, we saw there was a schedule for regular medicines safety audits. An audit of patients with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) had been undertaken to ensure records for patients had been reviewed in the preceding 12 months.
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