Pearl Medical Practice

We carried out an announced focused inspection at Pearl Medical Practice on 15 September 2021. Overall, the practice is rated as Requires Improvement.

Safe - Good

Effective - Requires Improvement

Well-led - Requires Improvement

Following our previous inspection on 18 February 2020, the practice was rated Requires Improvement overall and for key questions safe and well led, and good for providing effective, caring and responsive services.

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

Why we carried out this inspection

This inspection focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance. At the previous inspection we found:

• The provider had not undertaken risk assessments to ensure the health and safety of staff and people using the service.
• Systems and processes to ensure good governance in accordance with the fundamental standards of care required had not always identified the shortfalls within the service.

We also followed up on areas we identified the practice should improve at the last inspection. Specifically:

• Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
• Review staff’s understanding of the duty of candour.

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 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 have rated this practice as Requires Improvement overall and RI for all population groups.

We found that:

• Policies were monitored, reviewed and updated.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Staff dealt with patients with kindness and respect.
• The practice proactively sought feedback from patients, which it acted on.
• There was evidence of quality improvement activity.

We found a breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We also found the provider should:

• Continue to consider ways to improve uptake for cervical screening and childhood immunisations.
• Ensure that all staff are aware of who their Freedom to Speak Up Guardian is and how they can be contacted.
• Continue to consider ways to improve data not consistent with national targets, including diabetes and antibiotic prescribing.

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