The Station Practice

We carried out an announced inspection at The Station Practice between 27 April 2022 and 29 April 2022. Overall, the practice is rated as Requires Improvement.

The key questions are rated as:

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires Improvement

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

Why we carried out this inspection

At our last inspection of The Station Practice on 10 August 2021 we found significant concerns in the management of medicines and the provision of appropriate healthcare monitoring of patients. We took urgent action to impose conditions for the breaches of regulation. This inspection was a comprehensive inspection to follow up on these breaches of regulation.

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 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:

• The practice had taken significant steps to address concerns raised at the last inspection, to ensure they provided care in a way that kept patients safe and protected them from avoidable harm.
• The practice had improved systems to review patients prescribed high risk medicines and who were diagnosed with long term conditions.
• The provider had kept CQC informed through the submission of a monthly action plan, in compliance with their conditions of registration.
• Patients received effective care and treatment that met their needs.
• Staff 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 way the practice was led and managed promoted the delivery of person-centred care.
• The practice had undertaken significant work to address the backlog of correspondence and test results found at our last inspection. Failsafe measures were in place to reduce the risk of any future reoccurrence.

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

• Whilst we identified significant improvement, some concerns remained around the monitoring and prescribing of patients’ medicines, including those that were high risk. The changes made had not been fully embedded.
• Staff vaccination was not maintained in line with current national guidance relevant to their role.
• Action plans for health and safety, fire and legionella risks assessments were not in place in the practice.

We rated the practice as requires improvement for providing well-led services because:

• There had been significant improvement since our last inspection to address concerns.
• Leaders had demonstrated that they had a credible strategy to develop sustainable care.
• However, at this inspection we identified concerns around clinical governance.
• Health and safety risk assessments were not always accurate and managed in a way that provided appropriate reassurances that actions had been taken.

We found breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Keep under review and act where necessary to respond to patient feedback and experience on access to services.
• Establish further means to gather patient views including the establishment of the patient participation group (PPG).
• Continue to monitor the uptake of childhood immunisations and cervical screening.
• Keep staffing levels under review.

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