We carried out an announced focused inspection at Chevin Medical Practice on 6 and 14 October 2022. We inspected the key questions of safe, effective and well-led. The practice is rated as good overall and for all of the key questions.
Following our previous inspection on 7 October 2015, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Chevin Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities, due to the length of time since the last inspection.
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 by telephone.
- Reviewing questionnaires we sent to staff.
- 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.
- Site visits to all practice locations.
- Reviewing patient feedback.
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:
- Patients could access care and treatment in a timely way.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice had systems in place to manage risk so that if safety incidents occurred, they were investigated. Any learning from them was shared and used to improve the service and prevent recurrence of similar issues.
- Safeguarding systems, processes and practices had been developed, implemented and communicated to staff.
- The provider had undertaken a risk assessment regarding the requirement of disclosure and barring service checks for their administration staff, including those who acted in the capacity of a chaperone.
- Staff informed us they had access to policies, procedures and guidance relevant to their role and responsibilities, including clinical protocols.
- There was access to appropriate clinical equipment, including those required to deal with medical emergencies, such as resuscitation equipment.
- Infection prevention and control was appropriately managed to help safeguard people from COVID-19 and other associated infections.
- Staff told us that the management team was approachable and that they felt well supported.
Whilst we found no breach of regulations, the provider should:
- Improve the management of correspondence and test results.
- Improve the usage and management of tasks on the clinical system.
- Improve the process for and patient safety alerts to ensure any potential risks are discussed with affected paitents and appropriately documented.
- Improve processes to recall and review patients, particularly those with long-term conditions and patients who are prescribed high-risk medicines.
- Implement a system to ensure that supporting information for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions is accessible to staff.