Cornerways Surgery

We carried out an announced inspection at Cornerways Surgery on 26th and 28th April 2022. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective - Good

Caring – Good

Responsive – Good

Well-led - Requires improvement

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

Why we carried out this inspection.

We inspected the practice because it was newly registered as a partnership. This inspection was comprehensive and covered the safe, effective, caring, responsive and well-led key questions.

How we carried out the inspection.

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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
• A staff questionnaire

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:

• 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.
• The way the practice was managed promoted the delivery of person-centre, holistic care.
• Feedback from patients about their care was consistently positive. The practice scored above average in all areas of the national GP patient survey.
• Staff felt supported by their managers.
• Staff had the training required for their role and were encouraged to develop their skills.

We rated the practice as requires improvement for providing safe services because:

• Staff vaccination was not maintained in line with current UK Health Security Agency guidance relevant to their role.
• The practice did not have a policy and procedure for reporting and recording significant events. There was limited evidence to show that lessons learnt had been identified and shared.
• Risk assessments relating to health, safety and fire were not completed and reviewed by people with the qualifications, skills and experience to do so.
• The system for recording and acting on safety alerts was not always effective.
• Information required for recruitment and to confirm the ongoing registration status of clinical staff was not always complete.

We rated the practice as requires improvement for providing well-led services because;

• Leaders lacked oversight of some processes and therefore failed to identify risks when those processes did not operate as intended.
• The practice did not always act on appropriate and accurate information.

We rated the practice as good for providing caring services, however we identified the exceptionally positive feedback from patients as an area of outstanding practice. Patients felt that staff went ‘the extra mile’ and that their care and support exceeded their expectations.

We rated the practice as good for providing responsive services. However, we identified timely patient access to services and appointments as an area of outstanding practice.

We found two breaches of regulations. The provider must:

• Ensure safe care and treatment.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Regularly review and maintain an up to date safeguarding register.
• Ensure that the system for monitoring and recalling patients on high risk medicines and those with long-term conditions is fully embedded.

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