Blake House Surgery

We carried out an announced focused inspection at Blake House Surgery on 14 February 2022. We inspected the provision of Safe, Effective and Well-led services. We did not inspect the provision of Caring and Responsive services during this inspection.

Overall, the practice is rated as Requires Improvement. Safe - Requires Improvement

Effective - Good

Well-led – Requires Improvement

Following our previous inspection on 27 November 2017 the practice was rated Good overall and for all key questions.

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

Why we carried out this inspection

This inspection was a focused inspection incorporating remote searches, interviews of staff and a site visit.

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
• Conducting an interview with a Patient Participation Group Member
• A pre-site visit staff questionnaire

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 rated Safe and Well-led as requires Improvement because we found:

• Some staff recruitment records were incomplete, and some pre-employment checks had not been undertaken.
• The provider did not have clear safeguarding systems in place to keep patients safe. Not all staff were up to date with the appropriate level of safeguarding training for their role.
• Systems and processes to support fire safety had not been implemented effectively as the provider had not carried out regular fire alarm testing.
• The practice did not have clear and effective governance processes and systems in place.
• Staffing at Blake House Surgery was vulnerable due to the staff shortages and recruitment difficulties.
• There was no documented development or succession plan for the practice

We have rated the practice as Good for providing Effective services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• 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. Patients could access care and treatment in a timely way.
• The practice reviewed all patients on long term antibiotic treatment and recalled these patients for further assessment and changes to treatment were made where clinically appropriate.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed by the service receive appropriate training, professional development, and supervision to enable them to carry out the duties they are employed to perform.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The area where the provider should make improvements:

• The practice should improve the uptake of cervical screening.
• The practice should ensure all reception staff have completed sepsis training.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

We carried out an announced focused inspection at Blake House Surgery on 14 February 2022. We inspected the provision of Safe, Effective and Well-led services. We did not inspect the provision of Caring and Responsive services during this inspection.

Overall, the practice is rated as Requires Improvement. Safe - Requires Improvement

Effective - Good

Well-led – Requires Improvement

Following our previous inspection on 27 November 2017 the practice was rated Good overall and for all key questions.

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

Why we carried out this inspection

This inspection was a focused inspection incorporating remote searches, interviews of staff and a site visit.

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
• Conducting an interview with a Patient Participation Group Member
• A pre-site visit staff questionnaire

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 rated Safe and Well-led as requires Improvement because we found:

• Some staff recruitment records were incomplete, and some pre-employment checks had not been undertaken.
• The provider did not have clear safeguarding systems in place to keep patients safe. Not all staff were up to date with the appropriate level of safeguarding training for their role.
• Systems and processes to support fire safety had not been implemented effectively as the provider had not carried out regular fire alarm testing.
• The practice did not have clear and effective governance processes and systems in place.
• Staffing at Blake House Surgery was vulnerable due to the staff shortages and recruitment difficulties.
• There was no documented development or succession plan for the practice

We have rated the practice as Good for providing Effective services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• 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. Patients could access care and treatment in a timely way.
• The practice reviewed all patients on long term antibiotic treatment and recalled these patients for further assessment and changes to treatment were made where clinically appropriate.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed by the service receive appropriate training, professional development, and supervision to enable them to carry out the duties they are employed to perform.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The area where the provider should make improvements:

• The practice should improve the uptake of cervical screening.
• The practice should ensure all reception staff have completed sepsis training.

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