The Care Quality Commission
  • Doctor
  • GP practice

Cadbury Heath Healthcare

Overall: Outstanding read more about inspection ratings

Parkwall Road, Bristol, BS30 8HS (0117) 980 5700

Provided and run by:
Cadbury Heath Healthcare

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Cadbury Heath Healthcare on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Cadbury Heath Healthcare, you can give feedback on this service.

25 July 2019

During a routine inspection

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions (insert)

Safe

Effective

Caring

Responsive

Well Led

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 outstanding overall.

We rated the practice as good for providing safe services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.

We rated the practice as outstanding for providing effective services because:

  • Patients received effective care and treatment that supported the achievement of better outcomes than comparable services and promoted a good quality of life.
  • The practice undertook a wide range of quality improvement projects, across all areas of the service. These drove continued improvement to the care offered. For example, an End of Life care Quality Improvement Programme was undertaken to ensure patients had the knowledge and support needed to make informed choices regarding end of life plans.
  • There was an ethos of recognising potential and developing staff into roles that met staff development needs and aligned these with the business needs of the practice.
  • Staff were committed to working collaboratively with allied health professionals to ensure patients with complex needs received coordinated care.

We rated the practice as outstanding for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Carers were proactively identified and well supported for the roles they fulfilled.
  • Feedback from a variety of sources by people who use the service was positive.

We rated the practice as outstanding for providing responsive services because:

  • The practice organised and delivered services to meet patients’ needs.
  • Patients could access care and treatment in a timely way.
  • Patient satisfaction feedback was very positive and consistently better than comparable services.
  • Services were tailored to meet the needs of individual people and collaboration with the local community was integral to how services were developed.
  • Community links initiatives had been implemented to strengthen links between the practice and the local community. These included support for those living within deprived areas.
  • A volunteer driver service had been set up by the practice to ensure patients who were vulnerable through isolation and disability were able to get to the practice and other community services they may have been referred and signposted to.
  • The patient participation group (PPG) were an integral part to the practice ensuring care was delivered in a way that met people’s needs.

We rated the practice as outstanding for providing well led services because:

  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.

  • Governance and performance management arrangements were regularly reviewed and reflected best practice.
  • The practice was a member of the Clinical Research Network and an accredited Royal College of General Practitioner Research Ready Practice which gave ongoing opportunities for developing and improving patient care.
  • A comprehensive programme of quality improvement ensured that evaluating care given and

implementing improvements was a continuous cycle,

  • Close working with locality practices provided opportunities for sharing learning from incidents and complaints.
  • The strategy and business plan had been developed by the practice team, and staff were empowered to deliver against objectives.
  • There were high levels of staff satisfaction, resulting in consistently high levels of staff engagement.
  • There was strong collaboration and support across all staff groups which engendered an ethos of openness and a common focus on improving quality of care, patient and staff experiences.
  • There was a proactive approach to working with other organisations and strong links had been developed with local community groups and schools to improve care and tackle health inequalities.

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 desk based review did not include a visit

During a routine inspection

Letter from the Chief Inspector of General Practice

This is the report of a desk based review to follow up actions set following the inspection of Cadbury Heath Healthcare on 21 April 2015. On 21 April we found the practice to be good for providing effective, caring responsive and well managed services but it required improvement for providing safe services.

Following that inspection we said the provider must:

  • Ensure the security of blank prescriptions including instalment (blue) prescriptions for patients recovering from substance misuse.
  • Review how hygiene and infection control is managed and maintained to ensure appropriate standards of hygiene are achieved. Standards should include the cleanliness of all areas of the practice; updating the infection control policy and ensuring all staff have received role specific training in infection control.
  • Ensure equipment for use in emergencies is available at all times so that staff have access to it if needed.
  • Ensure equipment is calibrated and that portable electrical equipment is safe for use and maintain records to evidence this.
  • Ensure staff are aware of the location of emergency equipment so they are able to access it if needed.

In addition we said the provider should:

  • Review how risk assessments are recorded and maintained to ensure it is clear who is responsible for taking action to minimise risks to patient and staff safety
  • Review processes for checking GPs home visit bags to ensure equipment is in date and safe to use.
  • Ensure staff are aware of the staff with responsibility for child protection and safeguarding vulnerable adults so that in the event of cause for concern they know who they should report to.
  • Make training available in relation to the Mental Capacity Act 2005 so staff are aware of their responsibilities when dealing with patients who lack the capacity to consent to treatment.
  • Ensure staff training records are complete to reflect the training staff have completed.

During this desk based review we examined evidence including photographs and documented evidence related to staff training, risk assessment processes, equipment and prescription security. sent to us by the provider and we found:

  • The security of blank prescriptions had been improved and there were systems to ensure they were kept safely.
  • The infection control policy had been updated. There was a risk assessment for maintaining cleanliness and infection control arrangements had been audited. Staff had received training in infection control and hand hygiene and there had been a ‘deep clean’ of the premises.
  • There were arrangements in place to ensure emergency equipment was available and staff knew of its whereabouts.
  • The risk policy had been updated and there was a risk register and revised risk assessments in place.
  • The practice had introduced a system for checking GP home visit bags and we saw checks were carried out.
  • There was a list of those staff in the practice with lead responsibilities including child protection and safeguarding vulnerable adults and this was displayed in staff areas.
  • A record of staff training had been compiled, staff were completing individual training ‘passports’ and had attended training in the Mental Capacity Act 2005.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

21 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cadbury Heath Healthcare on 21 April 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for the older patients, those with long term conditions, patients of working age, students and the recently retired. In addition, it was good for providing services for families, children and young people, those whose circumstances make them vulnerable and patients with poor mental health, including those with dementia. It required improvement for providing safe services.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments 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 practice proactively sought feedback from staff and patients, which it acted on.

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

Importantly the provider must:

  • Ensure the security of blank prescriptions including instalment (blue) prescriptions.
  • Review how hygiene and infection control is managed and maintained to ensure appropriate standards of hygiene are achieved. Standards should include the cleanliness of all areas of the practice; updating the infection control policy and ensuring all staff have received role specific training in infection control.
  • Ensure equipment for use in emergencies is available at all times so that staff have access to it if needed.
  • Ensure staff are aware of the location of emergency equipment so they are able to access it if needed.

In addition the provider should:

  • Review how risk assessments are recorded and maintained to ensure it is clear who is responsible for taking action to minimise risks to patient and staff safety
  • Review processes for checking GPs bags to ensure equipment is in date and safe to use.
  • Ensure staff are aware of the staff with responsibility for child protection and safeguarding vulnerable adults so that in the event of cause for concern they know who they should report to.
  • Make training available in relation to the Mental Capacity Act 2005 so staff are aware of their responsibilities when dealing with patients who lack the capacity to consent to treatment.
  • Ensure staff training records are complete to reflect the training staff have completed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice