Archived: Cardinal Medical Practice

We carried out an announced inspection at Cardinal Medical Practice on 28 April 2022.

Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement.

Effective - Requires Improvement.

Caring - Good

Responsive - Requires Improvement.

Well-led - Requires Improvement.

When this service registered with us, it inherited the regulatory history and ratings of its predecessor. This is the first inspection of Cardinal Medical Practice under the registered provider Suffolk Primary Care who became the provider from April 2020. Following our previous inspection, under the previous provider the practice was rated good overall.

Suffolk Primary Care is a partnership of eleven GP surgeries covering a population of 134,000 patient across Suffolk. Cardinal Medical Practice serves 29,727 patients

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

Why we carried out this inspection

This inspection was a comprehensive inspection as the first inspection under the new provider registration and because risks had been identified through information we had received.

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.
• Staff questionnaires.

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.
• information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall

We found that:

• The practice had been through significant changes including two mergers (one with two other practices and then joining Suffolk Primary Care. All three practices became Cardinal Medical Practice in July 2021.
• In addition to the mergers, the practice due to the closure of a local practice accepted an additional 1500 patients and managed the impact of COVID-19 and the increased pressures the pandemic brought to providing health care.
• These significant changes challenged the practice in terms of consolidating resources and managing across three sites. Cardinal Medical Practice had been successful in gaining the permissions and funding for a new building which should be completed during 2024. Both patients and staff told us this was exciting as the existing premises do not make it easy for providing care, communicating and cohesive teamwork.
• Since the merger and prior to this inspection, the practice worked closely with the CCG with a detailed action plan. There were regular engagement meetings held where the practice, provider, CCG and on occasions the CQC met to review progress and gain assurance against the identified risks and issues.
• The practice generally provided care in a way that kept patients safe and protected them from avoidable harm. Areas of improvement had been made but others were required and some needed further embedding, monitoring and sustaining.
• Patients received effective care and treatment that met their needs. Areas of improvement had been made but some of these needed further embedding, monitoring and sustaining.
• Some test results had not been fully recorded and coded onto patients’ medical records to ensure accurate information for future decision making. We found that there was not a clear process to ensure all patient correspondence had been reviewed, acted upon and filed in a timely way.
• Some staff had not received an annual appraisal or review within the past 12 months.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way, but patients reported delays in contacting the practice via the telephone.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care, however they also recognised that despite the improvements they had made, further improvements were required. The provider and the practice were positive they would achieve these, they had an action plan that was regularly reviewed and monitored.

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.

In addition, the provider should:

• Continue to encourage patients with learning disability to attend for an annual health review.
• Continue to encourage patients to attend their cervical screening appointments.
• Review the training of staff and where appropriate staff should receive safeguarding level 2 training.
• Continue to review patient feedback and make improvements to patients’ satisfaction in accessing the practice in particular via the telephone.

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