Edridge Road Community Health Centre

We carried out an announced inspection at Edridge Road Community Health Centre. A remote clinical records review was undertaken on 28 September 2021, a short site visit was completed on 11 October 2021 and interviews with staff were held remotely between 27 – 29 September 2021. Overall, the practice is rated as Requires Improvement.

Safe – Requires Improvement

Effective - Good

Caring – Good

Responsive - Good

Well-led - Requires Improvement

This is the service’s first inspection.

Why we carried out this inspection

This inspection was a comprehensive inspection to rate the service following their recent registration with CQC.

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.
• Requesting staff feedback using surveys.
• 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 Good for all population groups.

We found:

• The vaccine cold chain had not been monitored in accordance with the practice’s policy.
• Staff vaccination records were not completed in line with the practice’s own policy.
• Expired equipment was found with the practice’s emergency equipment.
• Systems for medication management created a risk that patients on multiple medicines would not have reviews/monitoring undertaken for each medicine they were prescribed.
• One staff member was unable to outline the guidelines in respect of obtaining consent and assessing the capacity of minors.
• Some risks identified with infection control had not been acted upon; though we found that the practice was trying to engage with the building manager to try and get these issues addressed.
• Complaint responses did not contain information about organisations that patients could escalate complaints to.
• There had been little engagement with patients in respect of below average national patient survey scores related to care and treatment and access; though the practice had made some efforts to improve patient satisfaction in these areas.
• Rates of cervical screening were below target. However, this service was suspended during the early part of the pandemic and the practice had hired additional nursing staff and could refer patients to the local access hub where this service was available. Additionally, the practice had an annual turnover of approximately 50% which impacted on the practice’s ability to meet this and other targets.
• Some staff reported that members of the leadership team were not approachable.

However, we also found that:

• The practice had worked with the primary care network to provide both the first round of covid 19 vaccinations and booster jabs. The practice had reached out and offered support to those they had identified as having caring responsibilities.
• The was an extensive programme of quality improvement activity.
• There was a system to manage significant events.
• Patients prescribed high risk medicines were being monitored in line with guidance.
• Records we reviewed indicated that patients were receiving high quality care and treatment in line with current legislation and guidance.

We found breaches of regulations. The provider must:

• 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 provider should:

• Take action to improve approachability of leadership.
• Have staff refamiliarise themselves with requirements around capacity and consent.
• Review the patient list size with a view to increasing the number of patients identified as having caring responsibilities.
• Include information about organisations the practice can escalate concerns to if their unhappy with the practice’s complaint responses.
• Continue to engage with building managers to address issues related to infection control and legionella.
• Continue with work to improve uptake of childhood immunisations and cervical screening.

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