Witham Health Centre

We carried out an announced focused inspection at Witham Health Centre on 14 September 2021. In April 2021, the registration with the Care Quality Commission changed. The circumstances of the new registration did not constitute a substantial change in the management of the practice, therefore the regulatory history was transferred to the new legal entity, negating the need for a comprehensive inspection. Accordingly, we inspected safe, effective and well-led only.

Overall, the practice is rated as Good.

Safe - Good

Effective - Requires Improvement

Well-led - Good

The previous inspection was an announced comprehensive inspection at PK Mohanty & Partners, known as the Witham Health Centre on 30th May 2019 as part of our inspection programme. Following this inspection, the practice was rated Requires Improvement overall and Requires Improvement for providing safe and effective services. The practice was rated as Good for providing Caring, Responsive and Well-led services.

This practice was previously rated requires improvement when we carried out inspections in April 2017 and in March 2018.

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

Why we carried out this inspection

This inspection was a focused follow up inspection for the key questions, Safe, Effective and Well-led to follow up on:

A Requirement Notice issued following our last inspection relating to the following:

• Medicines and Healthcare Regulatory Agency alerts were not actioned, and oversight was not maintained.
• There was a lack of an effective system in place to improve performance over time in relation to QOF data for patients with long-term conditions and for patients suffering with poor mental health.

Also to review areas identified at our last inspection as a should:

• Ensure training of staff is kept up to date including fire and infection control.
• Continue to monitor and review the prescribing of antibiotics and hypnotics and all high-risk medicines.
• Continue to strengthen and monitor improvement relating to patient satisfaction.
• Monitor and review bowel cancer screenings and the number of new cancer cases treated which resulted from a two week wait (TWW) referral.
• Review current systems and process to identify carers to ensure they receive appropriate support.
• Review the guidance and legislation in relation to the storage and issue of controlled drugs in use at the practice, to ensure they are being followed.

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

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 and Requires Improvement for the population groups people with long-term conditions and working age people, (including those recently retired and students). The cumulative effect of rating these population groups in

this way meant that the Effective domain was rated as Requires improvement.

We found that:

We were satisfied that most of the concerns had been adequately addressed, but there were some areas that still needed further improvement, specifically:

• Outcomes for the population groups, patients with long term conditions and working age people (including those recently retired and students) were lower than local and national averages.
• The prescribing levels of some antibiotics was higher than the local and national averages.

We also found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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.

Whilst we found no breaches of regulations, the provider should:

• Continue to monitor and improve the prescribing of some antibiotics.
• Improve the monitoring and review of patients with COPD, diabetes, coronary heart disease, including health checks.
• Continue to improve cancer screening data.

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