The Reynard Surgery

We carried out an announced comprehensive inspection of The Reynard Surgery from 27 September to 4 October 2021. Overall, the practice is rated as requires improvement.

When this service registered with us, it inherited the regulatory history and ratings of its predecessor. Following our previous inspection of the predecessor, published on 11 December 2019, the practice was rated requires improvement overall and for providing safe, effective and well led services, and rated good for providing caring and responsive services. The population groups of people with long term conditions and people experiencing poor mental health including people with dementia were rated requires improvement in the effective domain. Due to our ratings principles, the effective domain was rated requires improvement. The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Reynard Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out an announced comprehensive inspection at the practice to review in detail the actions taken by the provider to improve the quality of care. The focus of this inspection included:

• The key questions of safe, effective, caring, responsive and well led.
• The follow up of areas where the provider ‘should’ improve identified at our previous inspection.

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:

• Requesting evidence from the provider and reviewing this.
• 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.
• Conducting staff interviews using video conferencing and by telephone.
• Gaining feedback from staff by using staff questionnaires.
• Requesting and reviewing feedback from the Patient Participation Group.
• 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 requires improvement for providing safe and effective services. The practice is rated requires improvement for the effective key question, as the issues identified affected all population groups, except for families, children and young people. The practice is rated good for providing caring, responsive and well led services.

We found that:

• Significant improvements had been made to the completion and oversight of recruitment checks, staff immunisation, staff appraisals, training, the oversight of nurses working in extended roles, policies and health and safety checks, including security. However, our inspection identified other areas for improvement as the practice did not always ensure the safe management of medicines.
• The most recent published Quality and Outcomes Framework (QOF) data showed an improvement to the practice performance was in line with the Clinical Commissioning Group and England averages for patients with long-term conditions and mental health needs. However, patients did not always receive effective care and treatment.
• 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 led and managed promoted the delivery of high-quality, person-centred care. All the staff questionnaire responses and staff interviews were very positive about the leadership and culture and the personal and professional support staff received from the practice. We identified some of the practice systems and processes in place to ensure good governance were not wholly effective. Where improvements were made immediately following our inspection, they needed to be monitored and embedded to ensure they were effective and sustained.

We found one breach of regulations. The provider must:

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

There were other areas the provider could improve and should:

• Continue to monitor and improve cervical cancer screening uptake.
• Continue to monitor the uptake of childhood immunisations to meet the 90% national target and the World Health Organisation target of 95% for all indicators.
• Embed the use of the new template for responding to complaints so patients are informed in writing of how to escalate a complaint to the Parliamentary and Health Service Ombudsman.

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