Ailsworth Medical Centre

Updated 23 November 2021

Ailsworth Medical Centre is located in Ailsworth, Peterborough, within the NHS Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) and provides services to approximately 4278 patients under the terms of a General Medical Services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.

The practice has two GP partners (both male) who hold managerial and financial responsibility for the practice. They are supported by a team of salaried GPs, practice nurses, and a small dispensary and administrative team. There is an on-site dispensary which we also visited and the practice was able to offer dispensing services to those patients on the practice list who lived more than one mile (1.6km) from their nearest pharmacy.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

The practice population has a deprivation index level of six, with one being the most deprived and ten being the least deprived. According to the latest available data, the ethnic make-up of the practice area is 95% White, 3% Asian, 2% Mixed.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.

Outside of practice opening hours patients are able to access pre-bookable evening and weekend appointments through a network of local practices. In addition to this, a service is provided by Herts Urgent Care, by patients dialling the NHS 111 service.

The practice is part of a wider network of GP practices with Nightingale Medical Centre and Westwood Clinic.

Updated 23 November 2021

We carried out an announced, focussed follow up inspection at Ailsworth Medical Centre on 14th October 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 25th June 2019, the practice was rated Good overall. We rated the practice as good for providing effective, caring, responsive and well led services and requires improvement for safe services. For all population groups we rated the practice as good apart from Families, children and young people which was rated as requires improvement.

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

Why we carried out this inspection

We carried out an announced, focussed follow up inspection at the practice to review in detail the actions taken by the provider to improve the quality of care. The focus of this inspection included:

• The key questions of safe, effective and well led.
• The follow up of the breach of regulation and areas where the provider ‘should’ improve, identified in our previous inspection.

The information we received and reviewed did not indicate the previous rating of good for providing caring and responsive services was affected and therefore we did not inspect these key questions and the ratings for providing caring and responsive services are carried over.

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:

• Requesting evidence from the provider and reviewing this.
• 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.
• Conducting staff interviews using video conferencing.
• Gaining feedback from staff by using staff questionnaires.
• Requesting and reviewing feedback from the Patient Participation Group.
• Requesting and reviewing staff questionnaires.
• 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 found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. The practice had made and sustained the improvements required to address the concerns identified in our last inspection.
• 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 high-quality, person-centre care.
• At our previous inspection, the practice had a lower performance in respect of the identification of carers. At this inspection, the practice demonstrated their improved approach to ensure that all carers were registered and their records coded. 153 patients (3.4%) of the patient population were now identified as carers.
• We found the practice system and process to ensure all medicines were linked to a diagnosis or particular problem was not always wholly effective.
• We found the practice system and process did not always ensure information for all patients with potential chronic kidney disease records was recorded.
• The practice told us they were reviewing the quality of their care plans to ensure they were comprehensive and shared with the patients.
• The practice had agreed plans to address any backlogs such as the reviews for patients with long term conditions.

Whilst we found no breaches of regulations, the provider should:

• Implement and monitor the action plan to address the backlog of long-term condition reviews.
• Monitor the system to ensure patient records are correctly coded and that medicines are linked to diagnosis or problems within the clinical record.
• Monitor and embed the systems and processes newly implemented to ensure all patients taking high-risk medicines are monitored appropriately.
• Continue to improve the system to ensure patient care plans are documented and in a format that is useful to patients and other health professionals.
• Continue to monitor and encourage patients/guardians to attend their appointments for baby immunisation and cervical screening.
• Monitor and embed the systems and processes newly implemented to ensure all patients are monitored appropriately.

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