Cranbrook Medical Centre Also known as Cranbrook Medical Practice

We carried out an announced inspection at Cranbrook Medical Practice on 18 May 2022. Overall, the practice is rated as Requires Improvement.

Safe Requires improvement

Effective Good

Caring Good

Responsive Requires improvement

Well-led Requires improvement

Following our previous focused inspection on 7 December 2021, an inspection

focused on the management of access to appointments, the practice was rated as Requires Improvement for the provision or responsive services.

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

Why we carried out this inspection

This inspection was a comprehensive inspection incorporating remote searches, interviews of staff and a site visit. The inspection looked at all the five key areas Safe, Effective, Caring, Responsive, Well Led.

How we carried out the inspection/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 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 rated Safe Responsive and Well-led as Requires Improvement because we found:

• Some staff recruitment records were incomplete or not up to date.
• The practice did not have a clear and effective process for managing risks, issues and performance.
• Clinical governance systems, including oversight of policies and procedures to keep patients and staff safe were not fully effective as they had not been fully developed and embedded.
• The practice did not have a system in place for formally discussing and recording significant events and the learning from them.
• The complaints process, whilst promoting duty of candour, did not provided an effective oversight of the complaints process and outcomes were not shared with the whole team, which would support learning and service improvements.

We rated the practice as Good for Caring and Effective services because:

• The practice provided care in a way that kept patients safe and protected from avoidable harm.
• The practice had provided staff training for receptionists to support care navigation since the previous inspection
• 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 way the practice was led and managed promoted the delivery of high-quality, person-centred care.

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.

The provider should:

• Develop a system to monitor the quality of access to services for patients.
• Review and improve processes to indentify and register carers, including young carers.

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