Oaks Place surgery

At our previous inspection on 21 August 2019, the practice was rated Good overall and for all population groups but Requires Improvement for providing safe services.

We carried out an announced focussed review of Oaks Place Surgery on 11 May 2021. Overall, the practice is rated as Good.

The rating for the key question followed up was:

Safe - Good

The other key questions remain unchanged as does the overall rating.

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

Why we carried out this review

This was a follow up review of information without undertaking a site visit inspection, to assess the Safe key question.

We reviewed the breach identified at the last inspection of Regulation 13 HSCA (RA) Regulations 2014 (Safeguarding service users from abuse and improper treatment). The regulation was not being met because systems were not in place for following up on vulnerable adults and children, who had missed appointments in secondary care.

We also reviewed the area where the previous inspection identified that the provider should make an improvement by:

• Consider alerts on patients records where they are subject to a Deprivation of Liberty Safeguard (DoLS).
• Providing formal training to non-clinical staff in the Mental Capacity Act 2005 and DoLS.
• Formalising the system for reviewing the practice of clinical staff to ensure consultations, referrals and prescribing are appropriate.
• Completing and reviewing the risk assessment for determining the medicines available at the practice in the emergency medicines kit.
• Completing and reviewing risk assessments for not taking medicines on home visits.
• Fully demonstrating the changes made as a result of audit findings.
• Monitoring hypnotic prescribing to effectively reduce this where possible.
• Recording the role specific induction covered with clinical staff.

How we carried out the 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 reviews differently.

This review was carried out in a way which enabled us to not conduct a site visit. This was in line with all data protection and information governance requirements.

This review included:

• Speaking with staff using video conferencing.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting and reviewing evidence from the provider.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we from this review
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We found that:

• The breach of regulation has been addressed and the practice had improved processes to provide care in a way that kept patients safe and protected them from avoidable harm.
• Alerts were on placed on patient records when they were subject to a DoLs.
• The practice ensured that non-clinical staff completed formal training in the Mental Capacity Act 2005 and DoLs.
• There was a formal system for reviewing the practice of clinical staff to ensure consultations, referrals and prescribing were appropriate.
• Risk assessments had been completed for determining the medicines available at the practice and in the emergency medicines kit as well as not taking medicines on home visits.
• Audit reports documented the changes in practice.
• Documentation of role specific induction for clinical staff was in place.
• There was ongoing monitoring and work to reduce hypnotic prescribing however the practice remained above local and national averages.

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