Archived: Hednesford Medical Practice

We carried out an announced comprehensive inspection at Hednesford Medical Practice on 5 February 2020 following a change in Provider. Due to a change of provider post April 2019, continuing regulated history has been applied.

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 previously carried out an announced comprehensive inspection at Hednesford Medical Practice on 18 January 2017. The overall rating was Requires Improvement. The practice was rated requires improvement for providing safe, caring and well-led services and good for providing effective and responsive services. We identified two breaches of legal requirements and served two requirement notices in relation to safe care and treatment and good governance. The report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Hednesford Medical Practice on our website at www.cqc.org.uk.

Following the retirement of one GP, the practice became a single-handed practice known and registered as Dr Chandra’s Surgery on 8 July 2017. Due to the GP being off work long-term, Dr Geeranavar oversaw the practice and became registered as an individual with CQC following the retirement of Dr Chandra.

We have rated this practice good overall and good for all population groups except for people experiencing poor mental health (including people with dementia), where we have rated this population group as requires improvement.

We rated the practice good overall because:

• Patients received effective care and treatment that met their needs and was planned and delivered according to evidence-based guidelines.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm. Some shortfalls we identified in providing safe services were promptly resolved by the provider.
• The practice had some evidence of quality improvement activity, however audits required further development.
• The practice understood the needs of its population and tailored services in response to those needs.
• The practice had identified 3% of patients as carers and supported and signposted carers to local support groups.
• Patients were satisfied with the with the service they received from the practice.
• Staff felt valued and supported in their work and in the development of their roles.
• There were clear responsibilities, roles and systems of accountability to support good governance and management.
• There was an open and transparent culture within the practice.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Leaders demonstrated that they had the capacity and skills to deliver high quality sustainable care. They were aware of their strengths and challenges and had acted to address any shortfalls.
• The practice had recently re-established their patient participation group and were working with them to improve patient experiences.
• The practice had a clear vision and credible strategy to provide high quality sustainable care.

The areas where the provider should make improvements are:

• Provide all staff with training in basic life support at the recommended frequency.
• Address the oustanding training for staff.
• Improve the monitoring of vaccine fridge temperature checks.
• Offer patients a chaperone where required.
• Explore and implement strategies to increase the uptake of childhood immunisations.
• Explore and implement strategies to increase the uptake of cervical cancer screening, breast and bowel cancer screening.
• Review and improve quality improvement activity.
• Continue to implement strategies to improve the management and care provided to patients experiencing poor mental health.

Following the inspection, the provider sent us a plan of the action they had taken in response to the concerns identified.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of General Practice