Archived: Churchwood Medical Practice

We carried out an announced comprehensive inspection at Churchwood Medical Practice on 13 November 2018 as part of our inspection programme following a period of special measures. The full comprehensive report on the November 2018 inspection can be found by selecting the ‘all reports’ link for Churchwood Medical Practice on our website at .

At the last comprehensive inspection in November 2018 we rated the practice as inadequate for providing safe and well-led services and overall, they were rated requires improvement for effective and responsive services and good for caring. This was because;

• Risk management processes were insufficient.
• Patients on repeat prescriptions did not have regular medicine reviews.
• The practice did not have sufficient systems to evaluate and improve practice and did not seek and act on feedback from relevant persons.
• Training and recruitment processes were insufficient.

At this inspection we found that the provider had made improvements in these areas.

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 requires improvement overall and for all population groups, they are rated as good in safe.

We found that:

• There was deterioration in the results of the GP patient survey around patient’s satisfaction in relation to their experience of consultations and in relation to accessing appointments. Changes to the way that patients accessed appointments had been implemented, however had not yet been evaluated in order to demonstrate improvements.
• A third of comment cards received during inspection showed that patients had experienced difficulties accessing appointments.
• Patients received effective care and treatment that met their needs and action was taken to improve patient outcomes in most areas. However, there was negative variation in relation to patients with diabetes and blood pressure control.
• The practice performance in relation to cervical screening was significantly below the national target.
• Action had been taken to improve medicine reviews for patients on repeat prescriptions.
• There was improved training compliance and supervision processes.
• Improvements to the recruitment processes had been made.
• Patient feedback during inspection and comment cards received showed that patients found that staff were kind and caring.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice had made improvements in the governance of the service, including in relation to the management of risk and acting on feedback to make improvements.
• A system had been implemented to track prescriptions within the practice and ensure that these were kept securely. However, we found printer prescriptions unlocked in an administrative room away from patient areas that had not been logged.
• Safety netting of the referral system for patients with suspected cancer referred to secondary care under the two-week rule was not always carried out in a timely way.

The areas where the provider must make improvements are:

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

In addition, the provider should:

• Review prescribing of nonsteroidal anti-inflammatory drugs (for the treatment of pain and inflammation) with a view to bringing this in line with average prescribing levels.
• Ensure that all printer prescriptions are kept securely and logged.
• Review safety netting processes for patients with suspected cancer referred to secondary care under the two-week rule and ensure processes are completed in a timely way.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

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

This practice is rated as inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Inadequate

This provider registered with CQC to provide the service on 27 November 2017. The service was inspected under the previous provider in November 2015 at which time it was rated good. We carried out an announced comprehensive inspection at Churchwood Medical Practice on 13 November 2018. This was the first inspection since their new registration and was carried out due to concerns raised.

At this inspection we found:

• Pre-employment checks undertaken by the practice were not thorough.
• 78% of patients had not received a medication review that required this.
• The practice overarching governance framework was not effective and did not support the practice to identify and act upon areas for improvement.
• The practice did not have a functioning patient participation group.
• The lack of leadership and oversight in the practice resulted in ineffective systems to identify and proactively manage risks and issues.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure that staff receive appropriate support, training professional development, supervision and appraisal as is necessary to carry out the duties they are employed to perform.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice