Leatside Health Centre

We carried out an announced inspection of Leatside Health Centre on 1 March 2022. Overall, the practice is rated as Good.

The key questions at this inspection are rated as:

Safe - Requires Improvement

Effective - Good

Well-led - Good

Leatside Health Centre is a newly registered practice following a merger in July 2021 of the Clinton Road Surgery and Manor Surgery. Our previous inspections of these two locations were carried out as follows;

Clinton Road Surgery November 2019 - rated Good

The Manor Surgery June 2016 - rated Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Clinton Road Surgery and Manor Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Cornwall. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

How we carried out the inspection/review

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 facilities
• 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 short 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

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm, however we couldn't be assured this was maintained at all times as some annual reviews had not been completed.
• The practice systems for reviewing safety alerts was not always carried out effectively.
• All staff had undertaken mandatory training appropriate to their role.
• Recruitment files contained all relevant information.
• Prescription stationery was stored securely in line with NHS guidelines.
• The practice had made adjustments associated with the COVID-19 pandemic to ensure that patients were kept safe and protected from avoidable harm.
• The practice was able to demonstrate staff had the skills, knowledge and experience to carry out their roles. Staff members were appraised annually and received appropriate supervision and training.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• Staff we spoke with told us they felt supported by the management team and if they raised concerns these would be listened to and acted upon.
• The practice had an open and supportive culture, where there was a focus on improvement.

We found breach of Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment. The provider must make sure they are following up to date guidance and have processes in place and follow them to:

• Ensure care and treatment is provided in a safe way to patients.

Also the provider should

• Continue to improve the service’s cervical screening uptake rates.

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