13/10/2022
During a routine inspection
We carried out an announced comprehensive inspection at The Uplands Medical Practice on 13 October 2022. Overall, the practice is rated as requires improvement. We found that since our last inspection improvements had been made in some areas, but further improvement was required in others.
Safe - good
Effective - requires improvement
Caring - requires improvement
Responsive - requires improvement
Well-led - requires improvement
Following our previous inspection full comprehensive inspection on 1 September 2021 the practice was rated requires improvement overall. The safe, effective, caring and responsive domains were rated as requires improvement. The well led domain was rated as inadequate.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Uplands Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this full comprehensive inspection in response to risk as the last inspection rated the practice as overall requires improvement. This inspection was a comprehensive inspection of all five key questions.
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.
- 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 have rated this practice as good for providing safe services because:
- Safeguarding systems were well managed.
- Health and safety and infection control had improved and were manged to keep patients safe.
- The safe use of medicines was promoted. Systems of medicines management had improved.
- Significant events and safety alerts were now well managed and shared with staff for learning.
We have rated this practice as requires improvement for providing effective, caring, responsive and well-led services because:
- Childhood immunisations and cervical screening data was below local and national average and required further improvement.
- Staff were now supported in their role with training and supervision.
- Clinical audits were carried out to ensure the ongoing improvement of the service.
- Patients raised concerns about trying to access the service and their overall experience of using the practice services.
- Carers were well supported.
- Patients had raised concerns with the CQC about the standard of the service provided.
- Complaint systems and process had improved and were now well managed.
- There was still a turnover of staff at the practice. A new practice manager had been employed and GPs had left resulting in the practice now using locum GPs.
- The practice governance arrangements had improved but further improvements were required regarding patient experience.
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.
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