Matching Green Surgery

We carried out an announced inspection at Matching Green Surgery on 15 June 2022. Overall, the practice is rated as Inadequate.

The ratings for each key question are:

Safe - Inadequate

Effective - Requires Improvement

Caring - Good

Responsive - Good

Well-led - Inadequate

We have not inspected this service since its registration as a new provider on 18 December 2020.

Why we carried out this inspection.

This inspection was a comprehensive inspection as part of our inspection programme.

We inspected all Key questions: Are services Safe, Effective, Responsive, Caring and Well-Led?

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 Inadequate overall

We found that:

• The practice systems and processes to keep people safe were not effective.

• The practice did not have an effective system in place to review children and adults with safeguarding concerns.
• The infection prevention control lead did not have additional training to support them in their role.
• The practice did not have effective risk assessments in place for the lack of emergency medicines. There was not an effective system in place to monitor the prescribing of controlled drugs.
• The system to recall patients who required monitoring or did not attend their appointments was not always effective.
• There was a lack of clinical oversight with the communication of test results with patients.
• Medicines reviews were not always completed.
• Systems for effective medicines management required reviewing.
• The practice did not have an embedded system to review the effectiveness of safety alerts.
• Patients’ needs were not always assessed in line with current legislation.
• Asthma care plans and dementia care plans were not always completed in line with best practice.
• Quality improvement was not embedded into the practice.
• There was limited monitoring of the outcomes of care and treatment.
• The practice could not evidence how they assured the competence of staff in advanced clinical practice.
• Although the practice had a vision and strategy, it was not being monitored to ensure effective care was provided to patients.
• Although the practice had some governance systems in place, these were not always effective or embedded in the organisation.

However, we also saw some areas of good practice. We found that:

• There was a positive and open culture at the practice.
• Child immunisations met World Health Organisation (WHO) based targets.
• The practice performed above CCG averages and sometimes England averages in the National GP Patient Survey results for most indicators.
• The practice deployed staff from the Primary Care Network to meet the needs of their patient population.
• Over the last year, the practice recruited additional staff to improve access and meet the needs of their patient population.

We found a breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Continue to engage with patients about involvement in the practice’s Patient Participation Group.
• Ensure the system to monitor delays in referrals is consistent amongst staff.
• Continue to improve the uptake of breast screening and bowel screening.
• Continue to embed the use of standardised care templates for Asthma care plans.
• Increase awareness of the Freedom to Speak Up Guardian at the practice.

Continue to inform patients and encourage consent of the sharing of information to improve integrated care.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. Special measures will give people who use the service the reassurance that the care they get should improve.

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