Site visit and staff interviews 15 September 2023, Records review 21 September 2023, Interview with partners 28 September 2023
During a routine inspection
We carried out an announced comprehensive inspection at Wallington Family Practice on 15 , 21 and 28 September 2023. Overall, the practice is rated as requires improvement.
Safe - requires improvement
Effective - requires improvement
Caring - good
Responsive - requires improvement
Well-led - requires improvement
Following our previous inspection on 9 September 2016, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Wallington Family Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection following a review of information we held. We inspected all of the key questions.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A shorter 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:
- There were gaps in systems to assess, monitor and manage risks to patient safety.
- Most patients received effective care and treatment that met their needs, but processes to ensure patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance were not always effective.
- The practice did not have a consistent and effective system to learn and make improvements when things went wrong.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patient satisfaction with access to appointments was in line with other practices nationally. The practice had made changes to how it organised and delivered services to try to better meet patients’ needs. Information as to the impact was incomplete, and it had not assessed whether the changes had made it harder for some patients to access services.
- There was considerable quality improvement activity, but it had not always been co-ordinated to ensure that it led to improvements in the quality of care.
- Staff treated patients with kindness, respect and compassion. Feedback from patients was generally positive about the way staff treated people, with above average satisfaction with healthcare staff recorded on the National GP Patient Survey.
- There was evidence that some governance systems had not worked effectively, particularly those to manage risk, and there was no effective overall oversight mechanism.
We found breaches of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should also:
- Continue to monitor and take action on areas of below average/below target performance in childhood immunisation and cervical screening.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care