The Care Quality Commission
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Heathcot Medical Practice

Overall: Requires improvement read more about inspection ratings

York House Medical Centre, Heathside Road, Woking, Surrey, GU22 7XL (01483) 761100

Provided and run by:
Heathcot Medical Practice

All Inspections

12 May 2022

During a routine inspection

We carried out an announced inspection at Heathcot Medical Centre on 9 - 12 May 2022. Overall, the practice is rated as Requires Improvement

Set out the ratings for each key question

Safe - Requires Improvement

Effective - Requires Improvement

Caring – Good

Responsive – Requires Improvement

Well-led - Requires Improvement

Following our previous inspection on 5 November 2018, the practice was rated Good overall and for the well led key question, we carried over the ratings for the other domains that were all rated as Good:

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

Why we carried out this inspection

This inspection was a comprehensive inspection looking at all of the domains. Safe, effective caring, responsive and well led.

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

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 Requires Improvement overall

We found that:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Staff told us they felt well supported and that leaders were approachable.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • There was a lack of monitoring of staff immunisations and risk assessments had not been undertaken to mitigate risks associated with a lack of immunisation.
  • Although the provider had a system in place to record and act on recent safety alerts, we identified a historic alert which had not been acted upon.
  • We found gaps in processes relating to the monitoring of vaccine fridge temperatures to ensure those medicines remained safe to use.
  • Staff recruitment files contained all of the required information.
  • Medicine reviews were not always completed in the required time frames.
  • Staff mandatory training was not up to date.
  • We saw evidence that clinicians took part in multi-disciplinary team meetings to discuss patient care.
  • The practice was innovative in the use of technology.
  • Urgent cancer referrals were not always being monitored to ensure that an appointment had been offered in the required time frames.
  • We found evidence of insufficient monitoring of a number of patient during our searches of patient records. This included high risk medicines, the follow up of abnormal test results and requests for repeat medicines.
  • The internal fire risk assessment did not cover all notable risks and there was no fire risk assessment completed for Knaphill Surgery.
  • Complaints investigation needed to be reviewed to ensure all of the concerns raised were investigated.
  • The details recorded for complaints and significant events needed to be strengthened to ensure trend analysis and the wider learning for all staff.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients
  • Ensure persons employed in the provision of the regulated activity receive the appropriate training necessary to enable them to carry out the duties.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

  • Review and continue to monitor cervical screening uptake to meet the Public Health England screening rate target.
  • Continue to plan and carry out staff appraisals.

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

9 October 2018

During an inspection looking at part of the service

This practice is rated as Good overall. (Previous rating October 2017 – Good overall and in all domains with the exception of well led which was rated as required improvement)

The key questions at this inspection are rated as:

Are services well-led? - Good

We carried out an announced focused inspection at Heathcot Medical Centre on 9 October 2018. This was to follow up on a breach of regulations identified at our previous inspection. At our previous inspection on the 11 October 2017 we found that the provider did not have complete records of recruitment and that staff training was not complete. The details of these can be found by selecting the ‘all reports’ link for Heathcot Medical Practice on our website at www.cqc.org.uk.

At this inspection we found:

  • Clinical and non-clinical staff training was complete.
  • The practice had addressed the concerns that were identified at our previous inspections and had complete records of recruitment checks.

The area where the provider should make improvements is:

  • Continue to develop processes for monitoring staff training

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

11 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Heathcot Medical Practice on 16 June 2016. The practice was rated as requires improvement for safe, responsive and well led services and good for effective and caring services. The overall rating for the practice was requires improvement. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Heathcot Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 11 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 16 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

  • The practice had reviewed their significant event processes and was ensuring learning outcomes and actions were shared appropriately with staff.
  • Blank prescription forms and pads were tracked and logged in line with national guidance.
  • All actions arising from the legionella risk assessment had been completed and the practice had arrangements in place to ensure future risks were mitigated.
  • A confidentiality sharing agreement had been made with the neighbouring practice.
  • Patient feedback from the GP national survey demonstrated an improvement in telephone access and appointments availability.
  • The practice had reviewed their policies and ensured they had been updated with appropriate information.
  • Recruitment arrangements included all necessary background checks for staff. However, references were not always actively followed up before employment commenced.
  • There were gaps in staff refresher training for adult and child safeguarding and infection control training.

During the last inspection, the practice had identified 214 patients as carers (1% of the practice population). The practice had reviewed their carers coding and improved identification of carers since June 2016. The number of identified carers had increased to 486 (4% of the practice list).

However, there were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

In addition the provider should:

  • Ensure all recruitment documentation is requested and followed up in line with practice policy.

The practice is now rated as good for safe and responsive and requires improvement for well led services. All six population groups have also been re-rated following these improvements and are also rated as good. Overall the practice is now rated as good.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

16 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Heathcot Medical Practice on 16 June 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, we noted that learning from these was not shared widely enough to support improvement.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks; completing actions identified by risk assessments and training.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Most patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However, some patients said that staff were rude to them and they felt the GPs did not listen to them.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they did not always find it easy to make an appointment with their preferred GP but urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw one areas of outstanding practice:

The practice provided a minor surgery service where patients could be referred from practices within the North West Surrey Clinical Commissioning Group. This extended over the contractual obligations which reduced waiting times and brought services closer to home. This service was provided to over 250 patients in the last year.We saw positive patient impact and outcomes as a result.

The areas where the provider must make improvement are:

  • Ensure all policies and protocols are reviewed regularly and contain up to date information.
  • Ensure training appropriate to job role is completed by all clinical and non-clinical staff and GPs, including induction, safeguarding children and vulnerable adults.
  • Ensure learning from significant events is shared widely enough to support improvement.
  • Ensure actions identified from risk assessments are completed and recorded. This includes actions from Legionella risk assessment.
  • Ensure recruitment arrangements include all necessary employment checks for all staff in accordance with Schedule three.
  • Review and improve patient satisfaction including customer care by reception, access to appointments and telephone access.

The areas where the provider should make improvement are:

  • Review how blank prescription forms are stored and tracked within the practice to ensure it is in accordance with national guidance.
  • Ensure that a confidentiality sharing agreement is in place with co-located services.
  • Pro-actively identify carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice