Godiva Group Practice Also known as Clay Lane Health Centre

Updated 24 August 2022

Godiva Group Practice provides a range of primary medical services to the residents of Coventry.

The practice and three branch sites are located at:

Gosford Green, Clay Lane Health Centre, Coventry.

Stoney Stanton , 475 Stoney Stanton Road, Coventry.

Holyhead, 1 Chester Street, Coventry.

Balliol Road Surgery, 1 Balliol Road, Coventry.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Coventry and Warwickshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 19,500. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices known as a primary care network (PCN). The PCN consisted of 12 local practices in total who work collaboratively to provide additional services to patients.

The practice population is predominantly white British with less than 4% of patients from minority ethnic backgrounds. Information published by Public Health England shows that deprivation within the practice population group is in the second highest decile (nine of 10). The lower the decile, the more deprived the practice population is relative to others.

The practice is led by a principal GP and three salaried GPs (one male and two female). The practice has a team consisting of an advanced nurse practitioner (ANP), five practice nurses and a pharmacist. The GPs are supported at the practice by the practice manager and a team of reception/administration staff. There are also care coordinators and social prescribers based in the practice premises.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most appointments were telephone consultations. The practice is open 8am to 6pm Monday to Friday and is closed at weekends.

When the practice is closed Out of hours services are provided by the NHS 111 service.

Updated 24 August 2022

We carried out an announced inspection at Godiva Group Practice on 4 May 2022. Overall, the practice is rated as Requires improvement.

The ratings for each key question:

Safe – Requires improvement.

Effective – Requires improvement.

Caring - Good.

Responsive - Good.

Well-led – Good.

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

We found that:

• The practice had a backlog of medicine reviews for patients prescribed certain high risk medicines and patients prescribed medicines to treat specific long term conditions. Although the practice had identified the issues and had a plan in place, plans were ongoing and we found there were still many patients who required a review. Actions were in their infancy and were yet to be embedded.
• Childhood immunisation and cervical screening uptake was below national expected levels. Uptake rates had declined since the last CQC inspection. Although the practice had identified the issues and had a plan in place, this was still in the process of being implemented and data showed lower rates than expected.

However,

• Patients mainly received effective care and treatment that met their needs.
• We observed staff dealt with patients with kindness and respect.
• 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.
• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care. The provider were aware of areas which required strengthening; such as medicines management and actions were ongoing.
• The practice team demonstrated a commitment to learning and improvement at all levels of the organisation.
• Clinical staff received regular updates and training and took steps to ensure they were familiar with the most recent clinical guidelines.
• There was a programme of quality improvement, including clinical audit.

We found breaches of regulations. The provider must:

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

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