Your Health Partnership (YHP) Also known as YHP-Regis Medical Centre

We carried out an announced comprehensive inspection at Your Health Partnership between 11 and 28 October 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement.

Effective - requires improvement.

Caring – good.

Responsive - requires improvement.

Well-led - requires improvement.

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities and to provide a rating for the service. The practice had not been inspected before under the current provider registration.

This was a comprehensive inspection and included all 5 key questions, to see if safe, effective, caring, responsive and well-led services were being provided.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff and focus group interviews using video conferencing. Interviews were held between 11 and 28 October 2022.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider before and after the site visit.
• A shorter site visit on 18 October 2022.

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 found that:

• Systems and processes that were implemented to keep patients and staff safe and protected from avoidable harm required improvement.
• Patients did not always receive effective care and treatment that met their needs.
• Not all staff had completed required training that was relevant for their role, including safeguarding and basic life support training.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could not always access care and treatment in a timely way. The senior management team were taking appropriate action to improve access for patients.
• Whilst governance processes required improvement, the senior leadership team demonstrated that they understood the challenges of delivering high-quality, person-centre care.
• The practice was part of a wider organisation that promoted joined up working between primary and secondary care to improve services for its patient population.

We found 2 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:

• Continue to improve uptake with children’s immunisations and cervical cancer screening.
• Take action to improve policies such as management of clinical waste and demonstrate they are working as intended.
• Take steps to ensure all staff have access to safeguarding information as relevant for their role.
• Take action to review patients with long term conditions and/or learning disabilities where reviews are indicated or records have been coded incorrectly.
• Continue to monitor and respond to patient feedback to improve access.
• Take action to be fully compliant with the accessible information standard.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services.