We carried out an announced focused inspection at Carpenters Practice on 01 March 2022. Overall, the practice is rated as Good.
Set out the ratings for each key question;
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led – Requires improvement
At the last inspection, the caring and responsive key questions were rated good. These ratings have been amalgamated with the ratings of this inspection.
We previously carried out an unannounced inspection on 30 April and 5 May 2021 as a result of concerns raised with CQC, we found the practice was in breach of Regulations 17 Good governance and 12 Safe care and treatment of the Health and Social Care Act 2008. In line with the CQC’s enforcement processes, we served a warning notice which required Carpenters Practice to comply with the regulations by 31 August 2021.
The practice was rated Inadequate overall (inadequate for key questions Safe, Effective and Well Led):
We carried out an announced focused inspection on 17 September 2021 at the Carpenters Practice site to check whether the provider had addressed the issues in the warning notices and now met the legal requirements. At that inspection we found the breaches of regulation in our warning notices had been complied with.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Carpenters Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This was an announced focused inspection which involved undertaking a site visit and a remote records review to follow up on breaches of regulations. We looked at Safe, Effective and Well Led key questions.
The data and evidence we reviewed in relation to responsive key question as part of our inspection did not suggest we needed to review the rating for Responsive and Caring at this time. The rating for Responsive and Caring remains rated as good.
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 remote 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 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 Good overall;
- At this inspection we found that safety issues previously identified had been addressed. However, there were some areas where control measures had been put in place to manage risk but leaders did not have oversight, for example oversight of the prescribing protocol.
- The practice managed patients on high-risk medicines according to evidence-based guidance.
- Although the practice had a documented approach to managing test results, we found it had not always been implemented effectively. For example, it was not clear that prescribers had checked monitoring was up to date and determined it was safe to prescribe.
- Risks associated with the premises were well managed and the provider had oversight of those risks managed by a third party.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- 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 high-quality, person-centre care. However, overall governance arrangements in place required improvement.
- There was a programme of quality improvement and performance analysis. Staff attended regular quality meetings to monitor performance.
We found a breach of regulations. The area where the provider must make improvements is:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
(Please see the specific details on action required at the end of this report).
The provider should:
- Continue to implement a programme to improve uptake for cervical screening and childhood immunisations.
- Improve compliance with policies and procedures; for example, the prescribing policy.
I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.
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