The Elms Medical Practice

Updated 31 January 2023

The registered provider is The Elms Medical Practice.

The Elms Medical Practice is located at Tilley Close, Hoo St Werburgh, Rochester, Kent, ME3 9AE. The practice is situated within the NHS Kent and Medway Integrated Care Board (ICB) and has a general medical services contract with NHS England for delivering primary care services to the local community.

As part of our inspection we visited The Elms Medical Practice, Tilley Close, Hoo St Werburgh, Rochester, Kent, ME3 9AE and Allhallows branch surgery, Avery Way, Allhallows, Rochester, Kent, ME3 9NY, where the provider delivers registered activities. The provider also delivers regulated activities at Grain branch surgery, Village Hall, Chapel Road, Grain, Rochester, Kent, ME3 0BY and High Halstow branch surgery, Recreation Hall, The Street, High Halstow, Rochester, Kent, ME3 8SF.

The Elms Medical Practice has a registered patient population of approximately 11,541 patients. The practice is located in an area with an average deprivation score.

There are arrangements with other providers to deliver services to patients outside of the practice’s working hours.

The practice staff consists of two GP partners, one salaried GP, two advanced nurse practitioners, two practice nurses, one healthcare assistant, one practice manager, one deputy practice manager, one human resources manager, one finance manager, one dispensary manager, one clinical pharmacist as well as reception and other administration staff. The practice also employs locum paramedic practitioners via an agency when required.

The Elms Medical Practice is a training practice: they are involved in the supervision and training of GP registrars as well as host medical students.

The Elms Medical Practice is registered with the Care Quality Commission (CQC) to deliver the following regulated activities: diagnostic and screening procedures; maternity and midwifery services; and treatment of disease, disorder or injury. At the time of our inspection the provider was in the process of updating their registration with CQC as one of the previous GP partners was now employed as a salaried GP.

Updated 31 January 2023

This practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

The full comprehensive report can be found by selecting the ‘all reports’ link for The Elms Medical Practice on our website at www.cqc.org.uk.

Why we carried out this inspection:

We carried out an announced inspection at The Elms Medical Practice on 6 and 7 December 2022 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

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 in line with all data protection and information governance requirements.

This included:

• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Requesting evidence from the provider
• A short site visit

Our judgement of the quality of care at this service is based 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.

Our findings:

We have rated this practice as Requires Improvement overall.

• The practice’s systems, practices and processes helped keep people safe and safeguarded from abuse.
• Some improvements were required to infection prevention and control systems and processes.
• The provider did not have all emergency equipment that was required to be kept.
• The arrangements for managing medicines did not always keep patients safe.
• The practice learned and made improvement when things went wrong.
• Improvements were required to some types of patient reviews.
• Staff had the skills, knowledge and experience to carry out their roles.
• Staff treated patients with kindness, respect and compassion.
• Staff helped patient to be involved in decisions about care and treatment.
• People were able to access care and treatment in a timely way.
• Processes for managing risks, issues and performance required improvement.
• The practice involved the public, staff and external partners to help ensure they delivered high-quality and sustainable care.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Continue to ensure the practice’s computer system alerts staff of children on the risk register as well as all family and other household members of those children.
• Continue with planned improvements to the documentation of referrals made under the two week wait system and monitor results.
• Consider updating reference links in Standard Operating Procedures (SOPs) that are out of date.
• Continue to ensure patient returned controlled drugs are disposed of in line with legislation.
• Consider improving staff knowledge of the accessible information standard.
• Consider formally recording the sharing of learning from all significant events being shared with relevant staff.
• Continue with ongoing action to improve and / or monitor performance relating to some childhood immunisations and some cancer screening.
• Continue to implement action plans and monitor improvements to patient satisfaction scores regarding access.
• Continue to make relevant changes to their registration with the Care Quality Commission in a timely manner.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

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