Greenlands Surgery

We carried out an announced inspection at Greenlands Surgery on 16 and 19 May 2022. Overall, the practice is rated as good.

Set out the ratings for each key question

Safe - requires improvement

Effective - good

Caring - good

Responsive - good

Well-led - good

Why we carried out this inspection

This inspection was a comprehensive inspection. It was the first inspection since the registration of the new partnership in 2020.

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

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

We found that:

• The practice had not always provided care in a way that kept patients safe and protected them from avoidable harm because recruitment policies were not always fully implemented and and there were some gaps in aspects of the recording and management of medicines and risk.
• Patients received effective care and treatment that met their needs.
• Staff treated 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.
• Data showed good levels of patient satisfaction with the service and no complaints had been received by either the practice or CQC.
• Appropriate standards of cleanliness and hygiene were met.
• The practice recognised the importance of their Patient Participation Group and acted on suggestions.
• The practice had a complaints policy and was open, honest and transparent when dealing with concerns and complaints.
• The way the practice was led and managed promoted the delivery of high-quality, person centred care. However, the governance and management systems did not always operate effectively, as concerns identified during the inspection had not been identified or resolved by the practice.

We found one breach of regulations. The provider must:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
• Ensure records of staff interviews and contract and terms and conditions are completed and held in staff files.

Although not a breach of regulations, the provider should:

• Review and improve their processes to notify staff that a patient is a parent/ guardian of a child on the safeguarding register.
• Review and improve aspects of the medicines management systems in relation to prescription safety and maintenance of the cold chain process for storage of vaccines.
• Review and improve the recording of action taken towards risk management systems including the management of safety alerts.
• Apply to add the regulated activity of maternity and midwifery services to their registration with the CQC.

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