Kent House Health Centre

We carried out an announced inspection at Kent House Health Centre on 5 May 2022 as part of our inspection programme.

The practice Kent House Health Centre has merged with two other local practices, Lyme Bay Medical Practice and Charmouth Medical Practice. The registered provider for this service is also known as Dr Forbes Watson Partnership. The provider is presently going through CQC’s registration process to reflect the change of name and address to the main location which is Lyme Bay Medical Practice.

Overall, the practice is rated as Good

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 19 June 2018 the practice was rated Good overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Kent House Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a fully comprehensive inspection incorporating remote searches, interviews of staff and a site visit.

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
• Requesting evidence from the provider
• A short site visit
• Staff Questionnaires.

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 rated Effective, Caring, Responsive and Well-led as Good because:

We found that:

• There was an open and transparent approach to safety and an effective system for reporting and recording significant events.
• The practice provided care in a way that kept patients protected from avoidable harm
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence-based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Feedback from patients about their care was consistently positive. The practice scored above the Clinical Commissioning Group (CCG) average in all areas of the national GP patient survey.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• 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.

We have rated this practice as requires improvement for Safe because:

• Staff vaccination was not maintained in line with Public Health England guidance relevant to their role.
• Information to confirm the ongoing registration status of clinical staff was not always complete.
• There were no risk assessments in place for emergency medications deemed not required.

We found breaches of regulations, the provider must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The area’s where the provider should make improvements:

• Review and monitor cervical screening uptake rates and continue to encourage eligible persons to attend for screening.

• Work towards staff completing equality and diversity training

• Work towards all staff understanding of the vision and values of the practice.

• Work towards completing the action plan as identified to maintain all staff training in relation to Infection Prevention and Control policy.

• Improve the learning from significant events to include non-clinical staff.

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