We carried out an announced inspection on 29 and 30 September 2021 to follow up on breaches of regulations identified at the previous inspection in August 2019. Overall, the practice is rated as Good. The key questions are rated as follows:
Safe - Requires improvement
Effective - Good
Well-led – Good
We carried out an announced comprehensive inspection at Braithwell Road Surgery on 1 August 2019 to follow up on breaches of regulations identified at a previous inspection on 17 December 2018. We rated the practice as requires improvement overall and for providing safe and well-led services because the practice did not have clear systems and processes to keep patients safe and there was a lack of monitoring by the provider.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Braithwell Road Surgery our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused follow-up inspection to follow up on:
- Breaches of regulations and recommendations identified in the previous inspection
- Ratings carried forward from the previous inspection
How we carried out the inspection/review
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 good for all population groups.
We found that:
- There was improvement in relation to management of safety alerts. However, the practice had not always provided care in a way that kept patients safe and protected them from avoidable harm. This is because they had not always completed the recommended monitoring for some prescribed medicines and recruitment procedures had not always been followed.
- Patients received effective care and treatment that met their needs.
- The practice had 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 had improved and promoted the delivery of high-quality, person-centred care.
We found two breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients
- Ensure specified information is available regarding each person employed
The provider should also:
- Obtain and record Information on staff vaccination status for non-clinical staff in line with the Department of Health Immunisation against infectious disease guidance (the Green Book).
- Implement training plans to support staff who have overdue training requirements.
- Review and improve accessibility of patient records relating to Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms and the systems to review these decisions.
- Review and improve patient engagement.
- Review and improve information for staff relating to the freedom to speak up guardian contact details.
- Review and improve the duty of candour procedures to detail how the duty of candour policy will be put into action.
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