Voyager Family Health

We carried out an announced comprehensive inspection at Voyager Family Health on 21 October 2022. Overall, the practice is rated as Requires improvement.

We rated the key questions as follows:

Safe – Requires improvement

Effective – Requires improvement

Caring – Good

Responsive – Good

Well-led – Requires improvement

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

Why we carried out this inspection

Voyager Family Health is a new provider which registered with the Care Quality Commission (CQC) on 10 March 2021 and is the result of a merger between two practices, Milestone Surgery and Southwood Practice. We carried out this inspection because the new provider has moved to a new location and has been operating for over 12 months and has never been inspected.

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 interviews using video conferencing facilities.
• 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.
• 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 rated the key questions of caring and responsive as Good. However, we rated the practice as Requires Improvement for providing safe, effective and well-led services because we found:

• A historic medicines safety alert from the Medicines and Healthcare products Regulatory Agency that had not been acted upon for 48 patients.
• An emergency medicine recommended in national guidance was not stocked and although the decision had been risk assessed, the control measures were insufficient to ensure safe care and treatment for patients.
• Patients taking high risk medicines were overdue routine monitoring tests to ensure prescribing was safe to continue.
• Patients with long term conditions were not receiving care and treatment in line with current best practice guidance.
• Patients records did not always contain up to date and accurate information to assist clinical decision making.
• A recall system existed but was not operating as effectively as intended because patients with the potential diagnosis of serious illnesses had not been recalled for further investigation.

We also found that:

• All staff had completed training in safeguarding children and adults to the level appropriate for their role and could speak confidently about what they would do if they had a concern.
• Recruitment systems and processes operated in accordance with the regulations.
• Infection prevention and control systems and processes ensured care and treatment given to patients was safe.
• Staff learnt form significant incidents when things went wrong.
• The practice had met the World Health Organisation targets for all childhood immunisations in the recommended schedule.
• The practice worked effectively with partners to ensure patients received care in a timely manner.
• The practice listened to feedback and responded to make improvements to the quality of care and access for patients.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• Data and information was used to drive improvement in the quality of care.
• Leadership and management were approachable, compassionate and inclusive.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found two 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.

In addition, the provider should:

• Continue the action plan to update all registrations with statutory organisations including CQC.
• Continue the action plan to obtain all relevant documentation from external contractors regarding the management of the premises.
• Continue the action plan to improve uptake of cervical screening appointments.

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