Naseby Medical Centre

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the COVID-19 pandemic. This was conducted with the consent of the provider.

At the last inspection in November 2019 we rated the practice as requires improvement overall; however, the practice was rated good in caring and responsive because:

• Training records for clinical staff who were not directly employed by the practice did not demonstrate that they were up to date with child safeguarding training and there were limited evidence of engagement with external healthcare professionals. Following our inspection, the provider submitted evidence demonstrating training and engagement.
• There were areas where clinical outcomes and screening rates were significantly below national averages or targets.
• The governance arrangements’ for managing the oversight of training, employment checks and embedding processes for recording significant events was not managed effectively.

We carried out an announced focused inspection at Naseby Medical Centre as part of our pilot inspection programme. The inspection consisted of remote interviews on 24 September 2020 and visiting the provider on 30th September 2020. A further site visit was carried out on 14th December 2020 to gain further information on how the provider managed people’s clinical needs. We decided to undertake the focus inspection in response to risk. This inspection looked at all five key questions.

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 and requires improvement for families, children and young people as well as working age people (including those recently retired and students) population groups.

We rated the practice as good for providing safe, caring, responsive and well-led services because:

• Staff articulated how they ensured patients were dealt with kindness and respect and involved them in decisions about their care.
• The 2020 national GP survey showed areas where patient satisfaction was above local and national averages. This was aligned with feedback from the practices internal 2020 patient survey
• The practice had an action plan aimed at improving patient access. For example, the practice demonstrated how they were seeking to upgrade the telecommunication system and patients were encouraged to use online services as a way of reducing the volume of incoming calls. The 2020 national GP patient survey showed patients were satisfied with their overall experience of making an appointment and with the appointment times.
• The practice had increased capacity within the nursing team which enabled the practice to offer more appointments for cervical screening and childhood immunisation programme. The practice had an action plan to improve uptake and data provided by the practice demonstrated an increase in the uptake of both cervical screening and childhood immunisations.
• At the time of the inspection we did not see plans to upgrade the IT system had progressed since the last inspection. However, following our inspection the provider sent supporting evidence which demonstrated a formal action plan was in place with clear timescales.
• Data we viewed during our first on-site visit did not provide assurance that systems in place to assure the quality of patient information including clinical data, such as read codes and diseases registers was effective. However, during our second on-site visit as part of this inspection, we saw no evidence that this had impacted on patients care and treatment.
• During our fist on-site visit as part of this inspection, we found that there was no clear audit trail to demonstrate actions taken in response to abnormal test results. Following our inspection, the provider made changes to how actions and requests were being documented.
• Vaccinations records were maintained in line with Public Health England (PHE) guidance for clinical staff. However, we were not provided with evidence for non-clinical staff. Following our inspection, the provider submitted evidence demonstrating non-clinical staff had received vaccinations.
• At the time of our first on-site visit, we did not see evidence that the provider actively engaged with key stakeholder to help improve the service and deliver high quality and sustainable care. Following our first on-site visit as part of this inspection, the provider submitted evidence demonstrating engagement and the development of an action plan to improve identified areas. The provider sent further evidence following our on-site visit confirming the upgrade of the IT infrastructure had been completed in line with the practice action plan.

We rated the practice as requires improvement for providing effective services because:

• Data over time indicated that actions taken to improve the uptake of national screening programmes and childhood immunisation had a slight impact; however, uptake rates continually remained below local and national averages.

The areas where the provider should make improvements are:

• Continue taking action to improve the uptake of childhood immunisation as well as national screening programmes such as cervical, bowel and breast cancer screening.
• Continue taking action in line with the practice action plan to improve patient satisfaction in relation to access.
• Take action to implement and embed clear governance arrangements to enable effective management of historical patient information which does not hinder data quality.
• Ensure upgrades to the IT infrastructure is well embedded.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.