Archived: Ravenscroft Medical Centre

We carried out an announced inspection at Ravenscroft Medical Centre on 16 March 2022. All key questions were rated good apart from ‘effective’. We rated ‘effective’ as requires improvement because we found the care for patients with long-term conditions required improvement (specifically asthma and hypothyroidism). The practice was responsive to these findings and provided evidence immediately following the inspection that actions were taken to begin to improve the care for patients with asthma and hypothyroidism. Overall, the practice is rated as Good.

Safe - Good

Effective - Requires Improvement

Caring - Good

Responsive – Good

Well-led - Good

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

Why we carried out this inspection

We carried out an inspection as the practice had changed management in 2019, this was the first inspection under the new management.

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
• 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.

We found that:

• Whilst long-term conditions were generally well managed, we found improvement was required for the management of asthma and hypothyroidism.
• The practice’s performance for childhood immunisations was lower than the national targets. The practice had already begun to make improvements in this area and provided evidence of improvements during the inspection.
• The practice completed a number of risk assessments to keep the premises safe, however the practice had not completed a fire risk assessment within the last 12 months.
• Although the practice used several methods to identify carers, the number of carers identified was less than one percent of the patient population.
• Whilst there were effective systems in place for managing patient safety alerts and safeguarding, fail safes were required for both systems.
• When something went wrong, there was an appropriate, thorough review that involved all relevant staff. Lessons were learned and communicated to support improvement.
• Services were planned and delivered in a way that met the needs of the local population.
• Patient satisfaction was in line with national targets.
• Leadership, governance and practice management arrangements promoted the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

• Continue to improve the treatment of asthma and hypothyroidism.
• Continue to improve childhood immunisations.
• Continue to risk assess the safety of the premises, including completing a fire risk assessment every 12 months
• Look at ways to increase the number of patients identified as carers.
• Continue to review the systems for safeguarding and management of patient safety alerts to ensure there are effective fail safes in place.

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