23 November 2022
During a routine inspection
We carried out an announced comprehensive inspection) at Glebedale Medical Practice on 23 November 2022. Overall, the practice is rated as Good.
Safe - Requires improvement
Effective -Good
Caring - Good
Responsive -Good
Well-led – Good
The previous Care Quality Commission inspection on 11 May 2021, the practice was rated Good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Glebedale Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities.
- We inspected, safe, effective, caring, responsive and well led key questions.
- We followed up on the ‘shoulds’ identified in the previous inspection
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on 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.
- A short site visit.
- Staff feedback questionnaires
- Speaking with other stakeholders such as care homes.
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 provided care in a way that kept patients safe and protected them from avoidable harm. However, some areas were identified in recruitment processes for improvement.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way. The practice had completed an in-house survey and implemented changes to further improve patient access.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice had recognised the need and had insight into the need to develop a measurable strategy.
We found a breach of regulations. The provider must:
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
The provider should:
- Document in full the actions taken by the practice to mitigate risk following a significant event or incident.
- Strengthen the systems for the validation and reconciliation of the practice safeguard registers with the appropriate local safeguarding social service team.
- Continue to improve the uptake of cervical screening.
- Continue to improve the uptake of childhood immunisations.
- Consider the need to close the branch site doors between 1pm and 2pm with safe staffing levels.
- Implement the suggestion made for the inclusion of a representative of each staff role at the practice meetings on a rotation basis.
- Continue with their activity to establish a Patient Participation Group (PPG).
- Continue with the development of a credible and measurable practice strategy.
- Engage staff with clear GP leadership and provide staff feedback on suggestions made and actions taken in response to feedback.
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