20 July 2022
During an inspection looking at part of the service
We carried out an announced focused inspection at Dr’s Bacon, Wrigley & Chomicka on 20 July 2022 Overall, the practice is rated as good.
Safe - Requires improvement
Effective – Good
Caring – Good (carried forward from previous inspection)
Responsive – Good (carried forward from previous inspection)
Well-led - Good
Following our previous inspection on 4 February 2016 the practice was rated Good overall and for all key questions.
The ratings for the key questions caring and responsive are carried forward from the previous inspection, these key questions have not been included in this inspection due to our methodology and no concerns were identified through the monitoring or inspection process.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr’s Bacon, Wrigley & Chomicka on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.
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:
- 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
- Staff questionnaires
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 Good overall
We found that:
- The processes in place for linking medicines to conditions was not always effective.
- The practice had a system for managing safety alerts but had not continued to monitor historical alerts and ensure safe prescribing for all patients.
- Although the practice and staff told us there was supervision and competency check for clinical staff, we did not see this was always formally recorded for future and proactive learning.
- Patients received effective care and treatment that met their needs.
- 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 person-centre care.
We found a breach of regulation. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
In addition, the provider should:
- Continue to improve the uptake of cervical screening.
- Continue to monitor and improve prescribing of antibacterial drugs.
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