The Heron GP Practice

We carried out an announced inspection at The Heron GP Practice on 9 and 10 March 2022. This was the first inspection since registration with the Care Quality Commission. Overall, the practice is rated as good and good in all key questions except safe, which was rated as requires improvement.

Why we carried out this inspection

This inspection was a comprehensive inspection undertaken as part of our routine inspection programme.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Leicester, Leicestershire and Rutland. 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

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
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit to both sites.

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 the practice as good for providing an effective, caring, responsive and well-led service. This was because:

• Staff told us they felt supported and valued in their work.
• The provider understood the strengths and challenges relating to the quality and future of services. They had identified the actions to address the challenges, for example, the need to engage with the local community to educate patients on the services available and how to make best use of them.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff had the skills, knowledge and experience to carry out their roles. There was a system in place to monitor compliance with staff training. Staff were encouraged and supported to develop their skills and knowledge.
• Systems were in place to assure the provider of the competency of staff working in advanced roles.
• Staff generally dealt with patients with kindness and respect and involved them in decisions about their care.
• 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.
• The practice was supported by the wider organisation, and staff were clear about the roles and responsibilities within the organisational structure.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing a safe service because:

• The provider did not require non-clinical staff who had direct contact with patients to be up to date with their routine immunisations or complete risk assessments for those staff whose immunisations were not up to date.
• Patient specific directions were not always in place to authorise the health care assistants to administer injections.
• The practice could not demonstrate that the cold chain had been effectively maintained, as on occasions the recorded fridge temperature had not been recorded or was outside of the required range of 2 to 8 degrees centigrade.

We found one breach of regulation. The provider must:

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

In addition, the provider should:

• Consider stocking all of the suggested medicines or complete a risk assessment for those medicines not held in stock.
• Record the relevant details of prescriptions when received into the practice.
• Continue to promote and drive the uptake of childhood immunisations and the cervical cancer screening programme with patients.

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