We carried out an announced follow up inspection at Wayside Medical Practice on 29 September 2021. Overall, the practice is rated as requires improvement.
Safe - Requires improvement
Effective – Requires improvement
Caring – Not inspected
Responsive – Not inspected
Well-led - Requires improvement
Following our previous inspection on 20 January 2020, the practice was rated requires improvement overall and requires improvement for safe and effective key questions. It was rated as good for caring and responsive and inadequate for well led. All six population groups were rated as requires improvement.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Wayside Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection.
This inspection was a follow-up inspection that focused on-:
- Safe, effective and well-led key questions
- Breaches of regulations 12 Safe care and treatment, 17 Good governance and 18 Staffing.
- Areas we said the practice should improve
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 requires improvement overall and requires improvement for the safe, effective and well led key questions. All six population groups are rated as requires improvement.
We found that:
- 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.
- The premises were clean and hygienic, and the practice had put enhanced infection control measures in place during the Covid-19 pandemic.
- Staff told us they felt supported by their managers and that their well-being had been a priority during the pandemic period.
- Staff had the training and skills required for their role.
- Recruitment checks were undertaken in line with regulations.
We rated the practice requires improvement for providing safe services because:
- Further to our inspections in December 2018 and January 2020 insufficient improvements had been made to the safe and proper management of high risk medicines.
- The system for recording and acting on drug safety alerts was not always effective.
- Test results were not always followed up appropriately in order to diagnose long term conditions. For example, diabetes.
- Staff did not always have the information they needed to deliver safe care and treatment.
We rated the practice as requires improvement for providing effective services because:
- Patients’ needs were not always assessed and care and treatment was not always delivered in line with current guidance.
- Insufficient improvements had been made in relation to some quality and outcomes framework indicators and childhood immunisations.
We rated the practice requires improvement for providing well-led services because:
- Leaders had not sufficiently addressed concerns raised at our previous two inspections in relation to the monitoring of high-risk medicines.
- Systems and processes were not operating as leaders intended. For example, the system for recording and acting on safety alerts.
- The practice did not always maintain accurate and complete patient records.
We found two breaches of regulations. The provider must:
- Ensure safe care and treatment.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
In addition the provider should:
- Maintain a central record of all staff training.
- Improve the uptake for cervical screening to ensure at least 80% coverage in line with the national target.
- Maintain a log of significant events to enable actions to be monitored and trends to be identified.
- Maintain accurate records of staff vaccination in line with current Public Health England (PHE) guidance.
- Re-establish systems for gathering and acting on patient feedback.
- Develop and implement a plan for audit and quality improvement.
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