We carried out an announced inspection at Eastmoor Health Centre on 10 June 2021. Overall, the practice is rated as Good.
Following our previous inspection on 12 November 2019, the practice was rated as good overall, with a rating of requires improvement for providing responsive services. All population groups were also rated as requires improvement. The practice had also been inspected under the previous provider in January 2018, when it was rated as requires improvement overall.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Eastmoor Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection.
This inspection was a focused inspection to follow up on concerns and issues identified at the last inspection, these included:
- Patient satisfaction regarding making and accessing appointments was significantly lower than local and national averages. Although at the time of the inspection in November 2019, the practice had introduced improvements to increase access to appointments, these systems still needed to be embedded and reviewed for their effectiveness.
At the last inspection it was also noted that the practice should make the following improvements:
- Review and improve child immunisation performance.
- Continue to monitor and review performance in relation to cancer screening, including cervical, breast, and bowel screening.
- Review staff training regarding child safeguarding to ensure staff have been trained to the appropriate level.
- Review and improve processes in relation to the recruitment of staff to ensure necessary references are obtained and criminal security checks have been made.
- Review staff feedback regarding issues of team tensions and the need to improve communication.
- Review processes to identify dementia patients to ensure that the dementia register was kept up to date.
- Review seating arrangements in the waiting area to improve privacy and confidentiality for patients discussing sensitive issues with members of the reception team.
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 and telephone interviews.
- 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.
This practice remains rated as good overall. Following this focused inspection, we rated the practice as good for providing responsive services and good for providing care for all population groups.
At this inspection we found that improvements had been made.
- We found that patient satisfaction in relation to appointment availability and access had improved and was comparable to local and national averages.
- The uptake of childhood immunisations had significantly improved at the practice. All five indicators were over the 90% minimum uptake rate. For example, the percentage of children aged one who had completed a primary course of immunisation was 100%. Appointments were offered to suit parents and their children and individualised care was prioritised.
- The team had developed a spreadsheet which was reviewed weekly and updated as necessary, which alerted the team when interventions, blood tests, ECGs and ongoing reviews were due. This included requests for further interventions from secondary care. Each action was reviewed and if patients had not booked the required intervention as previously requested, they were contacted by the team and a review arranged.
- The team continued to monitor and review performance in relation to cancer screening, including cervical, breast, and bowel screening. Additional capacity for staff to undertake reviews was in place, and local community links were established to highlight the need for the same. Verified data showed that uptake remained below local and national averages, but actions were in place to mitigate and improve outcomes. Patients could book screening appointments at a time and day to suit them.
- We saw that staff training regarding child safeguarding had been reviewed and updated to ensure staff had been trained to the appropriate level.
- The team had reviewed their processes for the identification of patients with dementia. Using a nationally recognised tool kit, the practice had conducted system searches and referred several patients for dementia reviews. Staff had completed dementia training and discussed with us their understanding that early diagnosis led to good quality outcomes for patients. Patients were signposted to local support groups.
- Processes in relation to the recruitment of staff to ensure necessary references and disclosure and barring checks (DBS) were in place. Where staff had been recruited historically, we saw that risk assessments were undertaken by the management team to assure themselves that the staff member was the right person for the role. Each staff member had completed DBS check.
- Staff told us they were able to raise concerns and were aware of the whistleblowing policy at the practice.
- Seating arrangements in the waiting area adhered to social distancing guidelines and had been reviewed to improve privacy and confidentiality for patients discussing sensitive issues with members of the reception team.
- Systems and processes were in place to manage and respond appropriately to patient complaints.
- The support offered to patients with a learning disability ensured that all those who required an annual health check were given the opportunity to attend.
Whilst we found no breaches of regulations, the provider should:
- Continue with plans to review and improve the uptake of cancer screening at the practice.
- Continue work to engage with their patients and establish a functioning patient participation group.
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