All inspections: The Wilbraham Surgery - Care Quality Commission

We carried out a review of the data available to us about The Wilbraham Surgery 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 The Wilbraham Surgery, you can give feedback on this service.

We carried out a desktop focused review of The Wilbraham Surgery on 11 July 2022.

We had previously inspected the practice in May 2021 where the practice’s overall rating was good, with the key question of Well-led rated as requires improvement. All other key questions were rated good.

We issued the practice with a requirement notice for a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance) following this previous inspection.

The full comprehensive report following the inspection in May 2021 can be found on our website here: https://www.cqc.org.uk

This desk top review focused on the following key questions:

Well-led

How we carried out the inspection/review

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 & reviews differently.

This review was carried out in a way which meant we did not need to visit the 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
Requesting evidence from the provider

We based our judgement of the quality of care at this service on a combination of:

what we found when we reviewed action plan from the provider
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 good overall and good for the well-led key question.

We found that:

The practice was able to demonstrate that improvements had been made to the areas of the well-led key question that had been raised as a concern at the inspection in May 2021. This included evidence of quality improvement activity, governance arrangements and the management and recording of DNACPRs.
The practice had complied with the requirement notice that had been issued in May 2021.

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

We carried out an announced inspection at The Wilbraham Surgery on 10 and 12 May 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led – Requires Improvement

Following our previous inspection on 1 October 2019 the practice was rated requires improvement overall and for the safe, effective and well-led key questions as well as for all population groups. The practice was rated good in the caring and responsive key questions. The rating of good has been carried over from the previous inspection for the caring and responsive key questions.

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

Why we carried out this inspection?

This inspection was a focused follow-up inspection to follow up on:

The safe, effective and well-led key questions
Breaches of regulations; 19 fit and proper persons employed and 17 Good governance.
The “Shoulds” (areas for further development) from the previous inspection report.

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
Clear and regular communication with 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 good overall and in the safe and effective key questions. The practice was rated requires improvement for providing well-led services and for the older people population group. All other population groups were rated good.

We found that:

The practice had made improvements in the safe key question, specifically in relation to recruitment procedures and systems to manage risk. We found that some gaps remained in relation to management of risk. The practice addressed these immediately.
The practice had made improvements in the effective key question in relation to training. The practice recognised that further quality improvement activity was required to continue with the improvements already implemented.
The practice was rated requires improvement for providing well-led services. Although we saw improvements made in relation to systems for patient safety, training, recruitment and oversight; further work and development was needed to ensure governance arrangements were fully effective and working as intended.

We found one outstanding feature:

The practice had sent out 4000 text messages via the clinical system to patients to gather demographic information about gender status, pronouns and sexual orientation as part of the “pride in practice” initiative. The practice received 1000 responses and was able to record this information on the patient’s medical records. This ensured that these patients were able to be referred to and identified as they wished. Patients also benefited from this because they would be able to access gender specific interventions that might be denied to them if their gender was different to the one assigned at birth. For example, cervical screening; trans men, who are not fully transitioned, still require cervical screening to ensure they are safeguarded from cervical cancer. If the clinical system does not reflect this, they may not be called for screening. The practice was awarded the gold award for “pride in practice” and was mentioned in a local primary care publication for this. The practice was also mentoring three other practices locally to replicate this work and working with the clinical system designers to make it more able to reflect these areas.

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.

The provider should also:

Identify vulnerable people on an ongoing basis, who are not covered by specific registers on the clinical system.
Implement the planned action to address any clinical backlogs.
Expand opportunities for learning in relation to significant events.
Implement the planned action to address lower than average childhood immunisation, cervical screening uptake 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

We carried out an announced comprehensive inspection at The Wilbraham Surgery on 1/10/2019 as part of our inspection programme. This was the first inspection of The Wilbraham Surgery since the new provider took over in May 2019.

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.

We rated the practice as requires improvement for providing safe services because:

The practice did not have clear systems and processes to keep patients safe.
There were gaps in systems to assess, monitor and manage risks to patient safety.
The practice did not have fully effective systems in place for the safe management of medicines.
The practice did not have an effective system to demonstrate action taken in response to safety alerts.

We rated the practice as requires improvement for providing effective services because:

The practice had achieved well in the quality and outcomes framework. However, it lacked a clearly defined approach to clinical audit as part of its approach to quality improvement.
The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.

These require improvement areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as requires improvement for providing well-led services because:

Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
While the practice had a clear vision, a strategy to support that vision had not been defined or documented.
The overall governance arrangements were ineffective.
The practice did not have clear and effective processes for managing risks, issues and performance.
The practice did not consistently involve the public, staff and external partners.
We saw little evidence of systems and processes for learning, continuous improvement and innovation.

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

Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
Staff helped patients to be involved in decisions about care and treatment.
The practice respected patients’ privacy and dignity.

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

The practice organised and delivered services to meet patients’ needs.
Patients were able to access care and treatment in a timely way. Patient feedback was highly positive around being able to see a clinician when they needed to.
Complaints were listened to and responded to and used to improve the quality of care provided.

The areas where the provider must make improvements are:

Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Record the action taken in response to safety alerts.
Ensure complaint information is kept separately from patient health records.
Develop a programme of clinical audit and quality Improvement

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

The Wilbraham Surgery

All Inspections

6 July 2023

During a monthly review of our data

11 July 2022

During an inspection looking at part of the service

12 May 2021

During an inspection looking at part of the service

1/10/2019

During a routine inspection